198400630-9-13-2022-54-CC-RDEO-CJ8QPG-20220913122042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400630
Report Date: 09/13/2022
Date Signed: 09/13/2022 12:20:52 PM

Document Has Been Signed on 09/13/2022 12:20 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	SHIRLEY FAMILY CHILD CARE		FACILITY NUMBER:	198400630
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	09/13/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Applicant - Lillian Shirley		TIME COMPLETED:	12:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Randy Derraco conducted an announced pre-licensing inspection to the above mentioned address on 09/13/22 at 09:50 AM. LPA met with applicant, Lillian Shirley, who guided LPA on a tour of the home. LPA did not observe any adults or children present during inspection. Per applicant, she is currently licensed to provide foster care. Individuals residing in the home have been noted and discussed. The applicant is requesting a small family childcare home license. Per applicant, operation hours will be Monday through Saturday, 6:00 AM to 6:00 PM. Applicant states that they will care for children 0-12 years old. All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single story home that consists of three bedrooms, one bathroom, living room, dining room, kitchen, laundry area, front yard (fenced) and back yard. Off limit areas include two bedrooms, laundry area and backyard. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. The main care area is located in the living room. LPA observed a window mounted air conditioning unit, two couches, a book shelf for children's reading materials, a television and television stand. The dining area was also observed to have child sized table and chairs, age appropriate toys, a glass table with high chairs, and a day bed. A wall mounted heater was observed in the dining area and is made inaccessible with a gate. A baby gate was observed in the kitchen, separating the off limits laundry area. Knives and other pointy objects were observed to be kept locked beneath the kitchen sink with the homes cleaning supplies. All cabinets in the kitchen area were observed with child locks making contents inaccessible. Per applicant, children in care will have access to bedroom #2. LPA observed a bunk bed, a twin sized bed, furniture and a television. Per applicant, children that are showing signs of illness will be separated into bedroom #2 while they await parent pick up. LPA observed the bathroom to be sanitary with an operable sink and toilet. A child lock was (page 1 of 3)

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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 3

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 198400630
	VISIT DATE: 09/13/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

observed beneath the bathroom sink making contents inaccessible. Outdoor play area is located in the front yard. LPA observed that the entry gate to the property is shared with two other addresses located in the back of the lot. Per applicant, neighbors walk straight through the gate at the side of the home to access their front door. Outdoor play equipment, tricycles, shade from the porch, and a basketball hoop were observed in the front yard play area.

Areas that will be used by children were inspected for safety, comfort, cleanliness. LPA observed operable telephone service, ventilation and heating. Detergents, cleaning compounds and hazardous items that can pose a danger to children are made inaccessible beneath the kitchen sink or in the off limits laundry area. The applicant was advised that any poisons must be locked, not just inaccessible. Children will nap on sleeping bags in the main care area. Parent board is located behind the front door in the main care area and was observed with required postings.

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 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.

LPA observed a pet dog kept in the off limits laundry area. Per applicant, there are no firearms or weapons stored in the home and there are no bodies of water. LPA observed that the Applicant has a 2A10 BC fire extinguisher in the home, with a service tag dated 06/29/22. Smoke and carbon monoxide detector were tested and are operable. The applicant states that they will provide food for children in care. Any food brought from the children’s homes shall be labeled with child’s name and properly stored or refrigerated.

The applicant has completed the required Health and Safety Training, Nutrition, and Lead Training, Mandated Reporter Training and Pediatric First Aid and CPR. Applicant has proof of required immunization's. Assistants have required training's and immunization's. There are first aid supplies available.

(page 2 of 3)

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 198400630
	VISIT DATE: 09/13/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Provided COVID-19 Technical Assistance by emailing applicant COVID-19 resources and self-assessment prior to visit. LPA discussed self-assessment and answered question regarding COVID-19

Incidental Medical Services (IMS):

This facility may provide 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.

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

LPA discussed and provided the following documents:
-PIN 20-24-CCP - Recently Approved Safe Sleep Regulations in Effect
-LIC 311D - Forms to keep in you Family Child Care Home
-LIC 9040 - Facility Roster
-LIC 624B - Unusual Incident Report
-California Child Passenger Safety Law flyer
-Small Family Child Care Home Capacity flyer

Applicant is requesting a small family child care license. A small family childcare license may be granted upon Licensing Program Manager (LPM) Approval. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.

Prior to license approval, the following correction must be completed:

-Shared walkway in the front yard must be made inaccessible to children in care.

Exit interview conducted and report was reviewed with the applicant Lillian Shirley.

(page 3 of 3)

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3