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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494797
Report Date: 04/01/2021
Date Signed: 04/01/2021 01:12:21 PM

Document Has Been Signed on 04/01/2021 01:12 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:GORE FAMILY CHILD CAREFACILITY NUMBER:
197494797
ADMINISTRATOR:GORE, ASAH-YANAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 245-3517
CITY:INGLEWOODSTATE: CAZIP CODE:
90304
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ASAH-YANAH GORETIME COMPLETED:
01:15 PM
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On 04/01/2021 at 10:30 AM Licensing Program Analysts (LPA) Stella Gutierrez conducted an announced Pre-licensing for the purpose of a change in location from 13220 Doty Avenue, Unit 121, Hawthorne CA 90250 License #197494228 . Visit was conducted as tele inspection via FaceTime with Applicant, Asah-Yanah Gore. Applicant was provided the Family Child Care Home self-certification check list prior to inspection and completed prior to inspection. Applicant guided LPA on a tour of the home inside and out via FaceTime due to social distancing in response of COVID-19. Applicant was informed that we are going to tour the home for a pre-licensing requirement per title 22 regulations and health and safety standard code requirements. Days of operation are Monday-Friday 6:00 AM- 6:00PM with all major holidays open. Applicant applied for a capacity of 14. Landlord consent not received. Fire Inspection conducted and granted before today’s inspection. Applicant stated that she will be providing care for ages 0-12 Years and if there are any changes to her plan of operation that she will contact CLLD prior to doing so to seek guidance.

Applicant was provided a Self-Assessment guide to follow in response to COVID-19 and was also informed that during today’s inspection that Licensing Program Analyst, Gutierrez will provide Technical Assistance in response to reducing the spread of COVID-19. Applicant was provided the following COVID-19 resources to refer to when in operation.

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-02-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-04-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN%2020-19-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN-20-11-CCP.pdf

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf Page 1 of 9

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
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https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-childcare.html

Areas identified in the sketch and inspected during today’s visit:

This is a single-story dwelling that consist of two different addresses (Two separate Units) Applicant’s unit is a single story that consist of a living room, kitchen, dining room, 3 bedrooms, 2 bathrooms and no laundry area. Backyard is accessible to applicant and other unit on the premises. There is an attached garage that belongs to other unit on the premises and is inaccessible to the children in care and applicant. Upon virtually entering the unit LPA, Gutierrez observed posters that discuss symptoms of COVID-19 and procedures to follow during the pandemic before entering the facility. Applicant was emailed these items for prior license and self-assessment with posters. LPA observed a touch free digital thermometer, hand sanitizer at the facility. Applicant was reminded to take daily temperatures and have children wash their hands when arriving to the facility. LPA, Gutierrez did not observe Wipes, tissues, clean pens, soap, disinfectant room spray and disinfectant counter top spray to sanitize care areas during COVID-19 during today’s inspection. Applicant was provided technical assistance to have these items while operating to reduce the spread of COVID-19.

Applicant stated that there are no in-ground or above-ground swimming pools, spas, fish ponds, decorative water feature, fountains or other bodies of water on the facility premises.


Applicant stated that there are no Fireplaces and open-face heaters on the premises.


Interior on limits areas:

Living room, Bedroom #1, Bedroom #2, Bathroom #1 and Bathroom #2. On limits areas inspected and the following was observed; Living room is where children will enter the facility. LPA, Gutierrez observed cubbies, circle time carpet, 2 sofas, Easel, Foam mats, small children's table with one chair and dramatic play area. Down hall area on right side is bedroom number #1 where main care area will be provided for toddlers and school age. LPA, Gutierrez observed circle time carpet, 2 shelves with cubbies, to tables with 6 chairs at each table, age appropriate games, toys and crafts. LPA, Gutierrez observed closet to have only 12 cots for toddler and school children to nap. Bathroom #1 room adjacent to bedroom #1 observed. LPA observed one toilet, one sink and bathtub that was operable. LPA, Gutierrez advised Licensee that soap, hand drying towels and essential toiletries shall be provided for the children that were not observed during todays inspection. COVID-19 hand washing procedures postings were advised. Page 2 of 9

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
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IMS Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.
Incidental Medical Services (IMS) policy was discussed When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US .Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

IMS plan of operation not provided but a statement by applicant that if providing IMS that a Incidental Medical Services Plan will be submitted to LPA before proving this service to children in care at any time at the facility.

Infant safe sleep consultation provided today-



Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

Safe sleep for your baby pamphlet and what does safe sleep look like wall flyer provided to applicant. Safe Sleep new flyer (5/23/2019) also given to applicant via postage mail.



LPA discussed safe sleep for infants with applicant: Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing. Keep a 15-minute check log of any infant she provides care for at the facility. Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
NARRATIVE
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Bedroom #2 inspected, LPA observed 2 pack n play yards. LPA, Gutierrez advised Applicant to refer to the manufactures manual for safe and proper usage. LPA observed age appropriate toys in this area. Applicant stated that this room will be used for the infants while operating and that this is also her children's room. There is an attached 1/2 bathroom (#2) with operable toilet and one operable sink. LPA, Gutierrez observe bathroom to have two training potty seats. There are no items kept under sink area. LPA, Gutierrez did not observe any soap or essential toiletries in bathroom #2.

Interior off limits areas:

Kitchen, dining room and bedroom #3. Kitchen inspected during today’s tele visit. There is a child safety gate that is in place between kitchen/dining area and the living room area to make inaccessible to the children in care. LPA, Gutierrez observed under sink to not have any items under and all drawers. Sharp items are kept in a drawer that is latched to make inaccessible. Dining room inspected to be the meal area for the children. Applicant was advised that off limits areas are prohibited for use during operation. Applicant stated that she will move the two children's tables from the dining area to living room area to keep inaccessible to the children. Bedroom #3 inspected to be inaccessible to the children in care by door kept shut and child proof door knob in place. The bedroom is where has a sofa and small desk. LPA did not observe any potential or immediate hazards in the bedroom and will be off limits to the children in care.

Exterior on limits area:

Back yard fenced in is accessed by exiting front door and to right of home through a side gate. Applicant stated that she will keep gate closed when children are in back yard. LPA Gutierrez observed on left side of home was another access point. Other unit back door is located on left side of home. LPA, Gutierrez advised Applicant that door must be kept shut and latched and to ensure 100 % supervision when the children are outside. Applicant stated that neighbors do not use and do not have authority to access back yard. Written declaration received today of back yard guidance given to applicant todays that she understands what was discussed.

Exterior off limits areas:

Left side yard and front yard other than when arriving or exiting the facility.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
NARRATIVE
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 The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.
·Changes should be reported the to the Department as soon as they occur such as construction and remodeling.

Telephone number changes and/or if you move from home
·Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department. (Child care Fire Drill log provided to applicant)
·There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.


Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
·Saucer chairs, bouncers, walkers, or any similar items are prohibited. (Flyer example of what these items may look like given to applicant today)
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
·Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
·LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov (Applicant currently receives quarterly updates)

The applicant was informed of the Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541


Email: childcareadvocatesprogram@dss.ca.gov
(Child Care Advocate Program Flyer given to applicant via postage mail)

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
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Emergency devices: LPA, Gutierrez observed a 2A-10BC Fire Extinguisher in living room/enterance to kitchen that applicant stated was purchased about one month ago. Picture provided in facility file. Operable dual smoke alarms and carbon monoxide detectors in living room, hallway and all bedrooms. 1st Aid Kit located in hallway closet that is equipped with ointment, thermometer, gauss, Band-Aids.

Facility Administration: Applicant completed training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Pediatric A certificate of completion of a course or courses in preventive health practices as defined in s subdivision (a) or certified copies of transcripts that identify the number of hours and the specific course or courses taken for training. (8 hours required) Preventative Health and Safety practices completed on 03/21/2021 and placed in facility file.

Pediatric First Aid and CPR expires 03/2023 for the applicant.


-Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be visiting regularly or for longer than one week.
·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
·Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The family day care home shall maintain documentation of the required immunization's or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.
·A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number) Page 4 of 9
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
NARRATIVE
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An exit interview was conducted, and a copy of this report was provided to the Applicant, Asah-Yanah Gore. Final decision of License issuance will be determined by the department unit Licensing Program Manager.

page 9 of 9

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
NARRATIVE
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FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Landlord Consent Form, if you plan to care for more than 6 children for a Small
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – renewed every two years.
Other documents given to Applicant: California Car Seat Law changes effective January 1, 2017, Ratio flyers for both small and large Family Child Care Homes, California Childcare Health Program Healthy Beverages in Child Care, Prohibited Items in child care family homes, Effects of Lead Exposure (CDSS Flyer), Child Care Advocate Program support sheet and “Keep me safe” printout.
A packet that includes the documents listed above were provided (via postage mail) and discussed.

Applicant was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Applicant was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations. Applicant receives quarterly updates.

The following items were discussed with the applicant to complete the application process:

1. Applicant will provide pictures of when completely moving in home and a follow up pre license inspection will be conducted.

2. Applicant will provide a Landlord Consent. Without consent applicant will be reduced ti a capacity of 12 from 14 upon approval of license. Please see page 9

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: GORE FAMILY CHILD CARE
FACILITY NUMBER: 197494797
VISIT DATE: 04/01/2021
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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.
Applicant was informed to refer to safe sleep regulations 102425 INFANT SAFE SLEEP for guidance when caring for infants at the GORE FAMILY CHILD CARE. LPA provided a copy via postage mail of the safe sleep regulations to Applicant. Applicant stated that she understands safe sleep for infants and will use best practices to ensure the safety of the infants cared for at the GORE FAMILY CHILD CARE. Licensing Program Analyst, Gutierrez was open for any questions or concerns regarding the safe sleep regulation and best practices. Applicant resumed with no questions or concerns at this time. 04/01/2021 at 11:45 AM.

SIDS & SHAKEN BABY SYNDROME INFORMATION LPA discussed flyer that will be mailed via postage mail to applicant today (Never Shake a Baby) Applicant will review flyer and understands the preventive practices of shaken baby syndrome and abusive head trauma.

FORMS TO BE POSTED
· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
COVID-19 related flyers and best practices

Children’s records requirements:


· LIC 700 Identification and Emergency Information
· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· Immunization record
· PUB 72- Family Child Care Consumer Guide
· LIC 995A Notification of Parent’s Rights
-CDPH PUB 286 (Immunization Blue Card) Page 7 of 9
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9