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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313989
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:17:12 PM

Document Has Been Signed on 09/19/2022 01:17 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SMITH, GABRIELLEFACILITY NUMBER:
304313989
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:LicenseeTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with Applicant, Gabrielle Smith. LPA also met with Elizabeth and Amelia Millares later on. At today's inspection LPA was notified of new age group of children the applicant will take care of. An application (LIC 279) was updated during this inspection for changes. LPA toured the facility with the applicant.

A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared.
Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if any future changes, to notify the licensing office.

Applicant is requesting for a Small Family childcare home license. Operation hours will be Monday to Friday 8:30 AM to 4:30 PM and care and supervision will be provided to children ages 2 to 6 years old.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a one story family home with 4 bedrooms, 2 full bathrooms, family room, kitchen with dining area, garage, and back yard with exit gate.
LPA observed storage for firearms which were locked. LPA observed the ammunition was stored and locked separately from firearms.
Areas that will be used by children were inspected for safety, comfort, cleanliness. Telephone service (cell phone is the primary contact phone. There is central heat and air conditioning in the home.
Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SMITH, GABRIELLE
FACILITY NUMBER: 304313989
VISIT DATE: 09/19/2022
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to children are inaccessible in areas designated for children stored in the locked cabinets. The applicant states that there are no poisons on the premises. Applicant was advised that any poisons must be locked with a key or combination lock.



Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated two bedrooms, and kitchen and garage as off limits on the first level.

There is a gate installed between the family room and kitchen to make the kitchen inaccessible to children. The kitchen cabinets and drawers are equipped with plastic locks in case children pass by the kitchen to go to the dinning area.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked. The master bedroom and two other bedrooms are locked with a child proof door knob on the handle of the doors.

The applicant will use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. The control of property was submitted and is on file.



Licensee was informed and understands the home is to be free from smoking during hours of operation.
Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Parents and children will enter the home, through the side back yard, opening into the back yard, and dinning room area and to the children's area. The designated day care area for napping, reading, eating have been set up with, books, toys, and activities. Children's area observed to have age appropriate activities and educational items for enrolled children. The sliding door in the dinning room opens to the back yard area which was concrete flooring and grass area and covered with rugs in other areas.

The bathroom is located in the passage between close to the bedrooms, it is a full bathroom, with small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink with safety latch

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SMITH, GABRIELLE
FACILITY NUMBER: 304313989
VISIT DATE: 09/19/2022
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installed. The children's bathroom was observed to be safe and free of hazardous items.

Applicant will provide morning snack and lunch and afternoon snack are provided to the children by parents. If food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

Upon entrance through the designated back yard gate of the home, applicant will receive the children here, due to pandemic parents are encouraged to follow CDC guidelines,

OUTDOOR PLAY AREA: Applicant will use the back yard for outdoor activities. It is all fenced with concrete flooring covered with soft rug, grass, and sand grass. It has age appropriate activity items for children in care. It is safe for outdoor activities. There is an emergency exit door with a latch stopper on the top and a combination lock. There is two swings and one slide and a climbing structure in the back yard on grass and sand area.

There are two chickens kept in a cage on the back yard area. There is a dog (Mini-Schnauzer) living in the house too. There is no bodies of water in the home. According to applicant there was an inflatable hot tub that they got rid of it.

The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has mounted the fire extinguisher on the side wall of the garage door. Smoke detector/ Carbon Monoxide is mounted on the ceiling of the passage area on the first floor.



Applicant has completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 014/2024. There are first aid supplies available.

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 certification, TB clearance along with a valid criminal record clearance associated to the facility license.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SMITH, GABRIELLE
FACILITY NUMBER: 304313989
VISIT DATE: 09/19/2022
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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 2A-10 BC 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.

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. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No Johnny jumpers, No Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian



LPA discussed the following items with the Applicant, Gabrielle Smith during the Exit interview:

Criminal Record statement: Applicant, Gabrielle Smith 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: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SMITH, GABRIELLE
FACILITY NUMBER: 304313989
VISIT DATE: 09/19/2022
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Safe Sleep : LPA discussed the safe sleep regulations with applicant, Gabriell Smith & 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 of the applicant, Gabrielle Smith 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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.

Review of records to be maintained : LPA reviewed with Applicant, Gabrielle Smith 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.

Subscribe to CCLD important information

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 license- 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 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

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SMITH, GABRIELLE
FACILITY NUMBER: 304313989
VISIT DATE: 09/19/2022
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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


OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements and additional forms were given to the applicant.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

The facility at the time of Pre-licensing inspection was not in compliance for a Small Family Child Care Home with Title 22 Regulations. The applicant corrected the following during the inspection.

The following corrections were observed corrected during LPA's inspection.


(1) The screen attached to fire place was secured to the wall during inspection.
(2) Stored knives were put away from the kitchen counter during inspection.
(3) Providing sheets for the crib in the napping area.
(4) Permission letters from two emergency locations were submitted to LPA during inspection.
(5) Propane gas for the outdoor barbecue equipment was put away in garage during inspection.
(6) The sand box were pulled away from the slide area during inspection.
(7) Updated documents of LIC 279 and LIC 999 and LIC 610 A were submitted to LPA during inspection,

Final License shall be approved upon, final file review and management approval.

Exit interview was held with applicant, Gabrielle Smith and appeal rights were presented.

End of reports
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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