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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494292
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:10:36 PM

Document Has Been Signed on 09/08/2021 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KARIS FAMILY CHILD CAREFACILITY NUMBER:
197494292
ADMINISTRATOR:BRENNA E KARISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(617) 529-2742
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Brenna KarisTIME COMPLETED:
03:25 PM
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On 09/08/2021 Licensing Program Analyst (LPA) Antonio Almanza, conducted an unannounced Annual Required Inspection and was met by Licensee, Brenna Karis. Also present were Staff #1 (S1) and Staff #2 (S2). Days and hours of operation are Monday to Friday 8:30 am to 5:30 pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the living room, dinning room and back bedroom are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locked door. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the living room and is made inaccessible by a child’s safety gate and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (617) 529-2742.

There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider is physically checking on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Pg 1.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KARIS FAMILY CHILD CARE
FACILITY NUMBER: 197494292
VISIT DATE: 09/08/2021
NARRATIVE
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Infants are not visually observed through an open door when sleeping in a separate room, LPA observed the door closed. Individual Infant Sleeping Plan (LIC9227 was provided to the license) is not completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. Pin 20-24-CCP was provided to the Licensee.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 12/16/2020. Licensee’s pediatric CPR/First Aid expires on 11/06/22. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home do not have a criminal record clearance or exemption. Staff 1 started working at the Child Care Home on or around June 22, 2021 and does not have a criminal record clearance on file. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KARIS FAMILY CHILD CARE
FACILITY NUMBER: 197494292
VISIT DATE: 09/08/2021
NARRATIVE
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Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, there are 1 Type A and 2 Type B Tdeficienc(y) being cited: (see next page, 809 D), Please see LIC421BG for Civil penalty assessed. Licensee was provided a copy of appeal rights.

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

Pg 3.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2021 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 09/08/2021 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KARIS FAMILY CHILD CARE
FACILITY NUMBER: 197494292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2021
Section Cited
CCR
102370(d)(1)

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102370 Criminal Record Clearance d) All individuals subject to a criminal record review ... shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption...
This Requirement is not met as evidenced by:
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Staff 2 has left the facility and will not be returning to work until a criminal record clearance and association to the facility has been completed.
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Based on observation, interview and record review, The Licensee did not make sure Staff 1 had a criminal record clearace, which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Licensee will make sure all adults have a criminal record clearacne prior to working, residing, or volunteering in the FCCH.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021


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Document Has Been Signed on 09/08/2021 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 09/08/2021 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KARIS FAMILY CHILD CARE
FACILITY NUMBER: 197494292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
CCR
102425(c)

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102425 Infant Safe Sleep (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.
This Requirement is not met as evidenced by:
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Licensee will have Infant Sleeping Plan LIC9227 filled out by parents and will review PIN Pin 20-24-CCP.
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Based on observation, interview and record review, The Licensee does not have LIC 9227 for 2 infants in care, which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Licensee will provide LPA copies of LIC 9227 for 2 infants in care and written statement that Pin 20-24-CCP will be adhered to via email by 09/10/2021.
Type B
09/10/2021
Section Cited
CCR102425(j)(5)

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102425 Infant Safe Sleep (5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.
This Requirement is not met as evidenced by:
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Licensee will provide LPA a written statement acknowldeging that the ddor to the infant room must remain open and that Pin 20-24-CCP will be adhered to via email by 09/10/2021
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Based on observation, interview and record review, The Licensee does not keep the infant room door open while infants are sleeping, which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021


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