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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845095
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:10:20 AM

Document Has Been Signed on 05/31/2024 11:10 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:GREEN FAMILY CHILD CAREFACILITY NUMBER:
364845095
ADMINISTRATOR/
DIRECTOR:		BRENDA GREENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 587-6270
CITY:ONTARIOSTATE: CAZIP CODE:
91764
CAPACITY: 14TOTAL ENROLLED CHILDREN: 17CENSUS: 4DATE:
05/31/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Leora Green TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On the date and time listed, Licensing Program Analyst (LPAs) Aman Lama and Raymond Moorehead arrived at the facility to conduct an annual inspection. Upon arrival, LPAs were met with assistant, Leora Green. Licensee granted access to LPAs who then toured the on-limits areas of the facility.
Normal days and hours of operation are listed as: 7 days a week, Monday-Monday, 12am-11pm.

The facilities new days and hours of operation are: M-F 4a-6p 8pm-4am, with a break from 6pm-8pm

The licensee is asked to submit an updated LIC279 with new hours, and any other changes that need to be made, along with any other forms that need to be updated.

OFF-LIMIT AREAS ARE LISTED AS FOLLOWS: Closet across the on-limit restroom on the first floor, and entire second floor and back porch area.


· A working telephone is present and current phone number is on file.

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector were all in working order.

· No hazards were accessible to daycare child(ren). Licensee was reminded the difference between which items to keep under lock and which to keep behind a latch, and how to read labels to determine.

· No guns/weapons currently kept in the home. All guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster were posted in the home.

· Mandated Reporter Training certificate for licensee exp 08/14/25, and for assistant expires 04/17/25.

· Pediatric CPR and First Aid Card for licensee expires 08/25 and for assistant expires 03/25.

SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364845095
VISIT DATE: 05/31/2024
NARRATIVE
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·Health & Safety Certificate has been completed by licensee is on file.

· Bodies of water were not observed directly on property at this time. There is a pool in the complex, but it is on the other side of the complex. All bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains were observed to be properly fenced per Title 22 Regulations. The Department must be notified before and after installation of any of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· LPA observed Clean, safe and age appropriate toys available for children.

· Documentation of last fire/disaster drills was available. Last drill conducted: 04-24.

· 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

· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations862@dss.ca.gov

-LPAs discussed the safe sleep regulations and discussed the Child Care Licensing Safe Sleep webpage as an additional resource at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

-LPAs 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.

-Licensee is not currently administering medications. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364845095
VISIT DATE: 05/31/2024
NARRATIVE
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-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

- The licensee 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200.

The licensees assistant, Leora Green 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 assistant, Leora Green.

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

SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/31/2024 11:10 AM - It Cannot Be Edited


Created By: Aman Lama On 05/31/2024 at 10:40 AM
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364845095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, assistant could not provide proof of immunizations during this insepction. Staff person stated that the licensee keeps it on file, but she's not sure where. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Facilty is asked to submit proof of immunizations - Measles (MMR), Pertussis (Tdap) and Flu shot or declination of flu shot no later than POC due date.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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, 4 out of 4 children did not have their immunizations on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Facility is asked to submit proof of immunizations for 4 out of 4 childrens files that were reviewed today. Moving forward, licensee understands that immunizations for any child not enrolled in school must be on file.
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:Aman Lama
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/31/2024 11:10 AM - It Cannot Be Edited


Created By: Aman Lama On 05/31/2024 at 10:40 AM
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364845095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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. 1 out of 4 children did not have the LIC995A signed by a parent/authorized representative. Although the form was on file, it was not filled out and signed off by the parent/authorized representative. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee agrees to submit proof of LIC995A for C4 no later than POC due date.

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:Aman Lama
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/31/2024 11:10 AM - It Cannot Be Edited


Created By: Aman Lama On 05/31/2024 at 10:40 AM
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364845095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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. There were no 15 minute checks available for review. Assistant stated that they do them, but could not locate where they are stored. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Immediately, facility agrees to begin conducting and keeping available 15 minute checks on file. Licensee agrees to submit proof of 15 minute checks done for two weeks that the facility is operating. Proof of these checks are due no later than the POC due date.
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:Aman Lama
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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