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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846156
Report Date: 03/07/2022
Date Signed: 03/07/2022 11:48:20 AM

Document Has Been Signed on 03/07/2022 11:48 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:GREEN FAMILY CHILD CAREFACILITY NUMBER:
364846156
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ebony Green and Essence Merriwether, ApplicantsTIME COMPLETED:
12:00 PM
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On 03/07/2022 at 8:30AM , Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct a Pre-licensing inspection. Present during this inspection were: Ebony Green and Essence Merriwether, Applicants. LPA toured the facility, inside and out and the following was observed and/or discussed:
Normal days and hours of operation are Monday- Friday; 6:00 AM- 6PM
OFF-LIMIT AREAS INCLUDE: 2nd floor, and Garage

The inspection consisted of reviews of the following domains: Physical Plant, Care and Supervision and Facility Administration.

· 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 cell
· All hazardous items inaccessible: Yes and located in locked cabinet.
· No guns or weapons present as of this date. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.
· Stairs are barricaded: Yes gated.
· No fireplace
· Storage of poisons is inaccessible to children and locked
· Verification of control of property on file: Grant deed observed and on file
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364846156
VISIT DATE: 03/07/2022
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· Facility Sketch and Emergency Disaster Plan are posted: Yes and located in hallway
· Pediatric CPR and First Aid Card - expire on 11/2023
· Health & Safety Certificate - completed on 10/18/2021
· Mandated reporter : General: 11/23/2019 Childcare expires: 11/2023
· Applicant 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. The Department must be notified before and after installation 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 when 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 gated.
· The Applicant 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
· 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
· 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 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: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364846156
VISIT DATE: 03/07/2022
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· Applicant 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 Applicant 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 applicant(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: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364846156
VISIT DATE: 03/07/2022
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- Pre-Licensing Visit Packet provided
- 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
- Once licensed, 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. Make propane table in back yard inaccessible

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. Applicant 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 Applicant 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 Applicants, Ebony Green and Essence Merriwether.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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