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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021083
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:49:55 AM

Document Has Been Signed on 11/01/2022 10:49 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HOLMES FAMILY CHILD CAREFACILITY NUMBER:
198021083
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Bridgette Holmes - ApplicantTIME COMPLETED:
11:00 AM
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At 9:03AM, Licensing Program Analyst (LPA) Steven Tung conducted a pre-licensing inspection to inspect and evaluate a facility for a Family Child Care Home. A risk assessment was conducted upon entry - appropriate PPE was used. LPA met with Applicant Bridgette Holmes who guided licensing staff on a tour of the facility. Operation hours will be Sunday - Saturday, 6AM – 6:00PM. Applicant states that she will care for children 0 years – 12 years of age.

All areas identified on the facility sketch were inspected. This is a one-story single resident house. The home consists of 2 bedrooms, 1 bathroom, living room, kitchen, backyard (fenced), front yard (not fenced), and an off-limits separate unit.

Per Applicant, the children will use all areas identified on the facility sketch with the exception of the separate unit. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone/land line), ventilation and heating. Home has central air and heat. Detergents and cleaning compounds were observed by LPA to be accessible by children in the hallway closet next to the bathroom. Licensee immediately removed the detergents and cleaning compounds and made them inaccessible to children. Per Applicant, there are no firearms or poisons in the home.

Based on the Facility Sketch submitted, the separate unit is off-limits to children. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

The children will use the backyard for outdoor play, which was observed to be gated and fenced. The area that the children are using was observed with toys.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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: HOLMES FAMILY CHILD CARE
FACILITY NUMBER: 198021083
VISIT DATE: 11/01/2022
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The 2A 10BC fire extinguisher in the facility was observed to have a purchase date of 10/31/22. The combination smoke and carbon monoxide detector in Bedroom #1 was observed to be operable and in good condition.

There are toys available for children in the indoor spaces. The applicant states that they will provide meals for children in care.

The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR. The First Aid Kit is located in the hallway closet next to Bedroom #1.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The following was discussed with the applicant:


- 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 Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
- Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
- The fire extinguisher type 2A10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
- Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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: HOLMES FAMILY CHILD CARE
FACILITY NUMBER: 198021083
VISIT DATE: 11/01/2022
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- Reporting Requirements: 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.
- Smoking is prohibited in a family child care home.
- Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
- No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
- Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
- The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
- Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
- Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.
- Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.
- Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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: HOLMES FAMILY CHILD CARE
FACILITY NUMBER: 198021083
VISIT DATE: 11/01/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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 advised the applicant how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.



LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.



Based on licensing staff observations, the following corrections need to be corrected prior to obtaining a family child care license. Corrections are due 11/15/22. Applicant will submit photos of corrections to LPA by correction due date.
- Applicant will make the fire place inaccessible to children.
- Applicant will obtain a children’s toilet seat.
- Applicant will obtain a table for the changing pad for infants.
- Applicant will remove the black metal poles next to the backyard shed so they are inaccessible to children.
- Applicant will make the back side of the backyard shed inaccessible to children.

Once corrections are made, the application will be submitted for final review to the department. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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: HOLMES FAMILY CHILD CARE
FACILITY NUMBER: 198021083
VISIT DATE: 11/01/2022
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Exit interview conducted and report was reviewed with the applicant Bridgette Holmes.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5