<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846201
Report Date: 05/06/2022
Date Signed: 05/06/2022 10:54:01 AM

Document Has Been Signed on 05/06/2022 10:54 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
334846201
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sarah Davis, LicenseeTIME COMPLETED:
11:00 AM
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
On 05/06/2022 at 8:30AM, Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct a Pre-licensing inspection for relocation. Present during this inspection were: Sarah Davis, Licensee. LPA toured the facility, inside and out and the following was observed and/or discussed:
Normal days and hours of operation are Monday- Friday; 6AM-6PM
OFF-LIMIT AREAS INCLUDE: 2nd floor, Garage, and Pool

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present, are in working order and were tested by the applicant during this inspection.
· The home has a working telephone: Yes landline/cell
· All hazardous items inaccessible: Yes and located
· No guns or weapons present as of this date. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.
· Stairs are barricaded: Yes
· The fireplace is properly screened: Yes
· Storage of poisons is inaccessible to children and locked
· Verification of control of property on file Mortgage statement
· Facility Sketch and Emergency Disaster Plan are posted: Yes and located in
· Pediatric CPR and First Aid Card - expire on 08/2023
· Health & Safety Certificate - completed on 08/27/17; Lead 04/20/22
· Mandated reporter : General: 09/15/2021; Childcare expires: 09/2023
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 334846201
VISIT DATE: 05/06/2022
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
· Licensee understands all bodies of water including ponds, above ground pools and spas, in-ground pools and spas, and some fountains must be properly covered or fenced per title 22 regulations. All wading pools/products must be emptied immediately and stored in an upright position if not in use.
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time and outdoor perimeter is secured with a fence and gates/secured.
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Issued applicant the following: SIDS information and Shaken Baby Syndrome pamphlet
· This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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

· 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
· 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 Applicant 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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 334846201
VISIT DATE: 05/06/2022
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
· Licensee 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.

As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and TB Screen and have your child submit for LIVESCAN background clearance.

· LPA reviewed with Licensee 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.
* Entrance Checklist was provided to the applicant.

· 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.

Additionally, The following was discussed with the Licensee(s):
- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.
- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 334846201
VISIT DATE: 05/06/2022
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
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter:
- Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited
- The Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days.
The Duty Officer is available to answer questions Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766).
Before licensure, the following needs to be corrected/completed:
1. Postings transferred from old facility
2. Make pool inaccessible- pool latch currently not self latching
3. IMS- submit plan for approval
4. Pictures of final placement for cribs
5. Statement from current co -licensee to remove from license.

Once all corrections have been verified, the application for a Small Family Child Care Home will be submitted for approval with a maximum capacity of 6, or 8 with parent notification. Licensee advised that all corrections are due within 30 days or the application may be withdrawn. An exit interview was conducted, and a copy of this report was provided to the applicant on this date.
During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
Exit interview conducted and report was reviewed with the Licensee, Sarah Davis. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4