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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494863
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:53:10 PM

Document Has Been Signed on 02/17/2023 03:53 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:HAGGERSTROM FAMILY CHILD CAREFACILITY NUMBER:
197494863
ADMINISTRATOR:CECILIA HAGGERSTROMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 633-3375
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Cecilia HaggerstromTIME COMPLETED:
03:00 PM
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On 2/17/2023 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual Required Inspection and was met by Cecilia Haggerstrom located on 2930 Delaware Avenue, Santa Monica, CA 90404.
Days and hours of operation are Monday through Friday 8 a.m. to 5:00 p.m. Currently applicant cares for children ages newborn to 3 years old but is open to care for children up to age 12 years. Licensee confirmed that facility does not provide overnight care or weekend care.

LPA toured the home inside and outside and a census was taken; 7 children were present during the inspection and two assistants. The home is a single-family home with 4 bedrooms and 3 bathroom, a living room, dining room, kitchen area laundry room area. LPA observed a detached garage and backyard.

Licensee confirmed the following areas are used for day care: bedroom 2, playroom and bathroom. Back yard is used as an outdoor space.

The following areas are confirmed as OFF LIMITS: Bedroom 1, Bedroom 3, Bedroom 4, bathroom 1 and bathroom 2, living room, dining room, kitchen and detached garage. LPA observed safety gate making the areas designated as OFF LIMITS inaccessible to the children in care.
There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection.

Detergents and cleaning compounds are kept locked in the bottom cabinet of the kitchen. Sharp object and knives were observed in the drawers in the kitchen- content inaccessible to the children in care- safety gates secure the playroom. Kitchen is OFF LIMITS.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 02/17/2023
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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 physically checks 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. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is 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. Licensee confirms that facility is checking on sleeping children every 15 minutes but log has not been created.
Adequate heating and ventilation for safety and comfort were observed in the space. LPA did no to observe any stairs in the home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number as 310- 903-0625.

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. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s file and 4 out of 6 files were missing proof of immunization. LPA discussed the LIC 311D- Records to be maintain in the facility and LIC 126 to use as a reference to audit files.

Staff files were not available for review. Pediatric CPR and First certification was reviewed, Licensee has current certification. LPA issued type B violation for incomplete files- MMR and Dpt and influenza was not available for review.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 02/17/2023
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Mandated Reporter Training was not available for review. Licensee agrees to complete training by 3/3/2023 and submit documentation to LPA. Licensee’s CPR and Pediatric First Aid was reviewed and observed to have an expiration date of 2/2024.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee Cecilia Haggerstrom.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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Document Has Been Signed on 02/17/2023 03:53 PM - It Cannot Be Edited


Created By: Judy Laureano On 02/17/2023 at 01:53 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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 files not having proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee agrees to submit proof of immunization to LPA via email 3/3/2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


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