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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019920
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:11:11 PM

Document Has Been Signed on 07/22/2022 02:11 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:MASON FAMILY CHILD CAREFACILITY NUMBER:
198019920
ADMINISTRATOR:JODI MASONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 298-9984
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jodi Mason - LicenseeTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced annual random inspection to the above facility. At 12:15pm, LPA met with licensee, Jodi Mason. Also present during this inspection were Licensee's assistants. The licensee states that she currently has 11 children enrolled. A current children’s roster is available and is current. Licensee’s hours of operation are 6am-5am, Monday-Friday

This is a one-story home which consists of 3 bedrooms, 3 bathroom, kitchen, dining area, living room, family room (day care room), detached garage, front yard and backyard (fenced). The children use the bathroom in the hallway, living room, kitchen, dining area, family room, backyard. Per licensee, areas off limits to children and parents include: the bedrooms, two bathrooms and the detached garage. All areas identified on the facility sketch were inspected. The licensee provides food for children in care.

The licensee states that 2 adults and 0 children currently live in the home. Persons living in home identified on attached LIC811. Licensee states that she currently has two assistant. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Per licensee, there is a firearm on the premises that meets Title 22 regulations. Storage details on attached LIC812.

PHYSICAL PLANT


At 12:20pm, LPA was lead on a tour of the facility by the licensee. The tour began in the front living room. There is a fireplace that is behind the couch and sealed. The area reviewed is the room adjacent to it that is used for children's learning activities. The storage of cots was observed in the corner of the room. There were age appropriate tables and chairs available. There is a hallway door closed with a safety handle on the doorknob that leads to where the bathroom is for children in care to use. LPA observed the bathroom to be clean and free of hazards. The tour continued in the back family room which is being utilized as the "day care room." It was nap time during the inspection. LPA observed age appropriate toys and equipment for children in care to use. REPORT CONTINUES PAGE 1 of 4
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MASON FAMILY CHILD CARE
FACILITY NUMBER: 198019920
VISIT DATE: 07/22/2022
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Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are observed to be posted on the wall of the daycare room. LPA observed the kitchen and the dining area next to it. Sharp knives were observed to be out of reach and high up in a cabinet above the oven. Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children, underneath the kitchen sink with safety latches. There are first aid supplies available. At 12:35pm, a fire extinguisher was observed in the kitchen. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 07/30/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. The licensee states that there is a land line on the premises. Smoke and carbon monoxide detectors were tested and are operable. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. Per licensee, the front living room will be used as an area for an ill child until an authorized representative comes to pick up child.

At 12:40pm, LPA observed the back yard area. The outdoor play area was observed to be fenced. At this time, children are using the back yard for outdoor play time. There are bikes and age appropriate toys and equipment for children in care to use. There is another fenced section of the backyard that has a swimming pool. LPA entered the area to review the pool. The pool has a 5ft gate surrounding the body of water. There is a self latching gate that opens away from the pool. The gate's latch is no more than 6 inches from the top of the gate and has a padlock on it. It is constructed as to not obscure the pool from view and is strong enough to withstand force against it. Each vertical railing of the gate is no mroe than 4in apart and the bottom of the gate is no more than 4in from the ground. Licensee states that the pool is used by the children on Fridays. The licensee is observed to be operating within the license capacity limitations.

FACILITY RECORDS:


The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 10/2023. Licensee and other personnel have not completed mandated reporter training. Licensee states they were unaware that it had to be renewed every two years. LPA discussed how to access the training for facility staff. The licensee does have proof of immunization against influenza, tuberculosis, pertussis, and measles. Children’s records were reviewed, including but not limited to, a copy of the emergency information card that contains all the information specified by regulation.
REPORT CONTINUES PAGE 2 of 4
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MASON FAMILY CHILD CARE
FACILITY NUMBER: 198019920
VISIT DATE: 07/22/2022
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The following was discussed:
-Individuals who are 18 years of age or older living in the home must be finger print cleared prior to being in the presence of the children in care. Individuals within one month of their 18th birthday must be fingerprinted immediately.
-There are no pets on the premises.
-Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that falls into these categories are not permitted in a family child care facility.
-Smoking is prohibited in a license family child care home.

Infant Care: Licensee states that they are currently caring for infants. LPA advised the licensee to sleep infants where they can be directly supervised at all times and advised the licensee against sleeping infants in a separate room. Licensee states that infants sleep in the daycare room. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices. PIN 20-24-CCP was provided and explained during the inspection.

Incidental Medical Services (IMS):


The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed COVID Health and Safety protocols with the licensee and observed sanitation and face masks during the inspection.

LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

REPORT CONTINUES PAGE 3 of 4

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MASON FAMILY CHILD CARE
FACILITY NUMBER: 198019920
VISIT DATE: 07/22/2022
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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

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative.
Exit interview was conducted with Licensee Jodi Mason, at 2:20pm, and Plan of Correction was reviewed and developed. A copy of the report was provided.

END OF REPORT PAGE 4 of 4
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2022 02:11 PM - It Cannot Be Edited


Created By: Nolan Tcheng On 07/22/2022 at 01:54 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: MASON FAMILY CHILD CARE
FACILITY NUMBER: 198019920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 facility personnel do not have a current Mandated Reporter Child Care Provider Training proof of completion, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Per Licensee, the facility personnel will complete the Mandated Reporter Child Care Provider Training and submit proof of completion to LPA 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:Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


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