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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495353
Report Date: 01/18/2024
Date Signed: 01/19/2024 10:22:15 AM

Document Has Been Signed on 01/19/2024 10:22 AM - 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:MASON FAMILY CHILD CAREFACILITY NUMBER:
197495353
ADMINISTRATOR:MYISHA MASONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 350-4088
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Myisha MasonTIME COMPLETED:
05:45 PM
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On 1/18/2024 Licensing Program Analyst (LPA) V. Wheatley conducted an announced inspection with applicant, Myisha Mason for the purpose of a pre-licensing inspection. The purpose of this inspection is for a new license to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes. LPA observed the applicant and the licensee's minor daughter on the premises.

The applicant is applying for a large family childcare license with a maximum capacity of 14. The applicant is renting the property and the property owner/landlord consent (LIC 9151) is currently on file which means the applicant qualifies for capacity 14.

Per the application, currently, the ages the applicant wishes to provide services for children 2 years to 13 years old with the hours of 6am to 5am, Monday through Saturday. Applicant was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes.

The home is three bedroom and two bathroom house. The care will be provided in the living room, dining room and one bedroom. The other two bedrooms are off limits and will remain inaccessible with door knob covers. LPA observed several toys and equipment. LPA observed all electrical outlets were covered and will remain inaccessible. The home has central heating and air conditioning. LPA inspected the bathroom which is safe. The kitchen is off limits and LPA observed all detergents and chemicals inaccessible. The applicant understands the children must be supervised at all times. LPA inspected the fenced backyard. The licensee will not use the yard until it is safe for children. A photograph of the yard will be emailed for approval prior to use.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 197495353
VISIT DATE: 01/18/2024
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LPA advised applicant to contact their local Resource and Referral Agency and inquiry about Food Program options. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. As a COVID precautions, LPA advised applicant to use disposable paper goods. LPA checked the smoke detector, carbon monoxide detector and fully charged 2A10BC fire extinguisher. LPA observed a fully stocked first aid kit. Applicant ordered the correct one during the inspection.

According to the applicant there are no pets, no firearms or bodies of water on the premises. LPA did not observe any of these items on the premises.

LPA reviewed the applicant's CPR/first aid which expires 12/2024.

The following items are pending and required to in order to be licensed:
*Fire Department Clearance for a large child care
*Two door knob covers for two bedroom doors
* LiC 610 - Emergency Disaster Plan completed
*Mandated Reporter Training (Child Care)
*The required immunizations for applicant
*Full copy of applicant's lease or rental agreement with signatures.

Exit interview conducted, and report was reviewed with the applicant. A copy of the report provided to applicant.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 197495353
VISIT DATE: 01/18/2024
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The following was discussed with the applicant:
Applicant was made aware 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 in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare 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 Address: childcareadvocatesprogram@dss.ca.gov

Immunizations: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.
Mandated Reporter Training: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.

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 also encouraged to read the P.I.N.S. and Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 197495353
VISIT DATE: 01/18/2024
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LPA discussed the safe sleep regulations with applicant 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 discussed Safe Sleep Regulations with licensee. Cribs and play yards will be 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 will physically check on sleeping infants every fifteen minutes and document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Individual Infant Sleeping Plan (LIC 9227) is required to be kept in file for each infant up to 12 months of age. Infants up to 12 months of age are required to be placed on their backs for sleeping.



LPA also informed applicant 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.

The applicant was informed regarding Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 197495353
VISIT DATE: 01/18/2024
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*Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.
*Applicant 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.
*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. 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)
*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.

*Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.
*Fire and safety drills must be performed every six months and documented for review by the Department.
*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.

*LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 197495353
VISIT DATE: 01/18/2024
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Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care.

FORMS TO BE POSTED


LIC203 Facility License
LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
Children’s Records Requirements:
LIC 700 Identification and Emergency Information
LIC 701 Child's Health History
LIC 627 Consent for Emergency Medical Treatment
LIC 282 Affidavit Regarding Liability Insurance
LIC 9150 Parent Notification Additional Children in Care
LIC 9166 Consent/Verification for Nebulizer Care (when required)
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
PM 286 California School Immunization Record (blue card)-http://www.dhs.ca.gov/publications/forms/immunization.htm
LIC 9224 Acknowledgement of Receipt of Licensing Report, if applicable.
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.
LIC 9151 Property Owner/Landlord Notification Form
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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