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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004718
Report Date: 06/09/2022
Date Signed: 06/09/2022 12:50:37 PM

Document Has Been Signed on 06/09/2022 12:50 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:UNDERWOOD FAMILY CHILD CAREFACILITY NUMBER:
198004718
ADMINISTRATOR:UNDERWOOD, GEORGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 814-8079
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brenae Underwood, AssistantTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced annual required inspection at the above facility on 06/09/22 at 8:30 AM. LPA met with Brenae Underwood, Licensee daughter/assistant who guided analyst on a tour of the facility at approximately 8:35 AM. There were 0 children and present when LPA arrived. Facility capacity is in compliance for a Large Family Child Care Home. There are 2 children and 2 adults that reside in the home. Licensee arrived at 11:06 AM with 1 minor that resides in the home licensee continued with the inspection.

This is a two-story home which consists of three bedrooms, three-bathrooms, kitchen, dining room,
living room, den attached garage, front and back yard (fenced).

Areas used by children were inspected as follows: Kitchen, family room, dining room, den, 1 bathroom on first floor, and back yard.

Areas off limits include: Attached garage, front yard, and entire upstairs (1 bed w/bath). **Rooms that are off-limits need to be made inaccessible during operating hours**.

Per Assistant parents come inside the facility on the left side of the house through a pathway leading to kitchen side door and the back door. LPA observed the following required posted documentation in the kitchen area where children come in: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log. Stated by Assistant stated a drill has not been conducted.
PAGE 1 OF 4
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 7
Document Has Been Signed on 06/09/2022 12:50 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 06/09/2022 at 12:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the outdoor back yard has pieces of wood panels, a metal pole attached to a cement piece, unsanitary table, plastic giant blocks, 5 level stand up storage plastic rack (not anchored), plant inside a ripped base, 2 exposed barbeque grills, next to the grills there is a metal table (under the grills and metal table there are foam mat that appear to be unsanitary, on the right side of the house in a pass way there are stacked up tiles, and a bucket all accessible to children in care. The licensee did not comply with the section cited above
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Per licenseee will submit proof by POC date.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Assistant and LPAs observation a fire drill log, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Per licenseee will submit proof by POC date.
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 Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/09/2022 12:50 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 06/09/2022 at 12:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review Child # 6 was missing proof , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Per licenseee he will submit proof by POC date.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review Child # 6 was missing proof , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Per licenseee he will submit proof by POC date.
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 Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/09/2022 12:50 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 06/09/2022 at 12:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review Child # 6 was missing proof , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Per licenseee he will submit proof by POC date.
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 Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


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Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718
VISIT DATE: 06/09/2022
NARRATIVE
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Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged date services 05/11/21. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate material available for children. LPA did not observe a wall heater. Detergents, cleaning compounds and medication are stored in in an area that is inaccessible to children. Assistant states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up in the dining area away from (LIC) 282- Affidavit Regarding Liability Insurance, other children. Per Assistant there are no firearms or weapons stored in the home.

Infant Care: Currently licensee does not care for infants. LPA discussed with Assistant the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months.

Children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. At 8:43 LPA observed a large play structure with a tunnel, swings, and a bridge, the right side of the structure was observed to be wobbly. LPA informed Assistant that this section needs to be reinforced LPA observed the structure to be anchored to the ground. Under the structure there are foam chips that can observe a fall. LPA observed a trampoline, licensee submitted a supervision declaration on 3/4/21. LPA observed that the outdoor back yard has pieces of wood panels, a metal pole attached to a cement piece, unsanitary table, plastic giant blocks, 5 level stand up storage plastic rack (not anchored), plant inside a ripped base, 2 exposed barbecue grills, next to the grills there is a metal table (under the grills and metal table there are foam mat that appear to be unsanitary, on the right side of the house in a pass way there are stacked up tiles, and a bucket all accessible to children in care.

Children’s records were reviewed for Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). Child # 6 is missing proof: LIC 700, LIC 627, LIC 995A.


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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718
VISIT DATE: 06/09/2022
NARRATIVE
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Staff records were reviewed for approved Pediatric First Aid and CPR certification, dated: 09/2023 LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate dated: 3/9/2022.
LPA did not observe childcare children.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Deficiencies cited on today’s visit, see LIC 809D.

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/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.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: UNDERWOOD FAMILY CHILD CARE
FACILITY NUMBER: 198004718
VISIT DATE: 06/09/2022
NARRATIVE
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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 George Underwood.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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