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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364804137
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:54:34 PM

Document Has Been Signed on 06/04/2024 02:54 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
364804137
ADMINISTRATOR/
DIRECTOR:		SANDRA DAVISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 421-3617
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
06/04/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee Sandra Davis TIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 6-4-2024 and time listed above, Licensing Program Analyst (LPA) Steven Montoya arrived at the facility to conduct an annual inspection. LPA was granted entry by Licensee, Sandra Davis..LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Days and hours of operation are Monday- Friday, 6am to ;6pm. OFF-LIMIT AREAS INCLUDE: Upstairs, downstairs laundry room and the garage.

The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited/not cited this visit.

The facility is operating within the licensed capacity and appropriate ratios. Licensee is present in the home and appropriate supervision is provided: A working telephone is present. Appropriate fire extinguisher: smoke and carbon monoxide detectors are present and were tested by the Licensee during this inspection- All hazardous items are inaccessible which could pose a danger to children. Storage of poisons/toxins are locked.- No fireplace. Fireplace is properly screened- Stairs are properly barricaded – Yes. Facility is clean, orderly and has adequate heating and ventilation- Yes. Facility has safe and age-appropriate toys for both indoor and outdoor activities Yes. Outdoor play area is fenced- Yes. Verification of control of property on file: Yes

SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137
VISIT DATE: 06/04/2024
NARRATIVE
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Property owner/landlord notification and consent on file Pediatric CPR and First Aid Card expires on: 8-2022 Health & Safety Certificate - completed on file Mandated reporter: Child Care Expires: 8-2022 Fire clearance: Documentation of fire & earthquake completed. Last drill not provided. LIC809D Children’s records are complete: Employee records are complete: No guns or weapons present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.

There are no bodies of water during this visit Licensee understands all bodies of water must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water.



Additionally, the following was reviewed with Licensee.
- 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

The California Department of Social Services’ (CDSS) Health and Safety Section (HSS) would like to announce the launching of the new Incident Reporting Portal. Effective immediately, rather than filling out the CDSS Incident Report (GEN 1311) and/or the CDSS Emergency Incident Form (GEN 1363), all Incident Reports are to be reported through the Incident Reporting Portal. This electronic submittal process will improve the tracking and processing efficiencies of incident reports.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137
VISIT DATE: 06/04/2024
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Licensee provided the Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov
The Duty Officer is available to answer questions Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766)

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

MyChildCarePlan.org – Family Child Care Homes Licensee Sandra Davis was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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: https://www.ada.gov/resources/child-care-centers/.



Licensee Sandra Davis was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee Sandra Davis and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe sleep as an additional resource. LPA also informed Licensee Sandra Davis 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: Ana Noble
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137
VISIT DATE: 06/04/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

During the exit interview, the Licensee Sandra Davis, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the Licensee Sandra Davis.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2024 02:54 PM - It Cannot Be Edited


Created By: Steven Montoya On 06/04/2024 at 02:30 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 Living room and Kitchen which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will clean up all downstair rooms and provided evidence of clean up to LPA via email photos. Steven.montoya@dss.ca.gov.
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [1] out of [1) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will clean up carpet and provided evidence of clean up to LPA via email photos. Steven.montoya@dss.ca.gov.
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:Ana Noble
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2024 02:54 PM - It Cannot Be Edited


Created By: Steven Montoya On 06/04/2024 at 02:30 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of records, the licensee did not comply with the section cited above in [1] out of [1] [Fire Drills), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will complete fire drill and document to provide to LPA via email. Steven.montoya@dss.ca.gov.
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:Ana Noble
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2024 02:54 PM - It Cannot Be Edited


Created By: Steven Montoya On 06/04/2024 at 02:30 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [1 [(Document emergency drills. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will document emergency drills and provided evidence of clean up to LPA via email photos. Steven.montoya@dss.ca.gov.

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:Ana Noble
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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