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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846173
Report Date: 02/09/2024
Date Signed: 02/09/2024 05:13:28 PM

Document Has Been Signed on 02/09/2024 05:13 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:DONG FAMILY CHILD CAREFACILITY NUMBER:
364846173
ADMINISTRATOR:DONG,AMYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
6268409997
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
02/09/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Amy Dong, LicenseeTIME COMPLETED:
05:25 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Taityana Benson arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday – Friday, 8:30 a.m. to 6:00 p.m.

OFF-LIMIT AREAS INCLUDE: Entire 2nd Floor, Garage, Downstairs Bedroom, Laundry Room, Both Side Yards (Backyard)

The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened with a glass door to prevent access by children
· All hazardous items are stored inaccessible to children
· Toxins are not locked (See LIC809-D)
· Weapons are not present according to Licensee, Amy Dong. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded with a plastic gate
· Verification of control of property on file (Tax Assessment)


Report Continued On LIC809-C
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 9
Document Has Been Signed on 02/09/2024 05:13 PM - It Cannot Be Edited


Created By: Taityana Benson On 02/09/2024 at 03:58 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: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

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. Poisons, detergents, and cleaning compounds are in the downstairs bathroom (countertop/shelf), washer room (cabinets), and backyard barbeque grill (countertop), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agrees to place all poisons, detergents, and cleaning compounds that are in the downstairs bathroom (countertop/shelf), washer room (cabinets), and backyard barbeque grill (countertop) in a key locked area and provide proof to LPA via email by COB 02/12/2024.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 02/09/2024 05:13 PM - It Cannot Be Edited


Created By: Taityana Benson On 02/09/2024 at 03:58 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: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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. S1 and S2 Mandated Reporter Training - Child Care Providers (AB1207) was completed on 01/05/2022 and there is not a current Mandated Reporter Certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee agrees to have S1 and S2 complete the Mandated Reporter Training - Child Care Providers (AB1207) and provide proof of completion to LPA via email by COB 02/23/2024.
www.mandatedreporterca.com
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 record review, the licensee did not comply with the section cited above. S2 does not have the Tdap (Pertussis) vaccination on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee agrees to have S2 obtain/complete the Tdap (Pertussis) vaccination and provide proof/copy immunization record to LPA via email by COB on 02/23/2024.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2024 05:13 PM - It Cannot Be Edited


Created By: Taityana Benson On 02/09/2024 at 03:58 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: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. C4 does not have a immunization record on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee agress to obtain an immunization record for C4 and provide proof/copy to LPA via email by COB on 02/23/2024.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 02/09/2024 05:13 PM - It Cannot Be Edited


Created By: Taityana Benson On 02/09/2024 at 03:58 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: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

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. C6 does not have the bottom portion of the Family Child Care Home Notification of Parent's Rights, LIC995A on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee agrees to provide LIC995A to the parent of C6, obtain the signed bottom portion and maintain the bottom portion in C6 file. Licensee agrees to provide LPA with proof/copy of the signed bottom portion of LIC995A via email by the COB 02/23/2024.

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:Kimberly Williams
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173
VISIT DATE: 02/09/2024
NARRATIVE
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·Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training expired on 01/05/2024 (See LIC809-D)
· Pediatric CPR and First Aid Card expire on 09/16/2025
· Health & Safety Certificate - completed on 12/18/2021
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & 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.
· Clean, safe and age appropriate toys
· Current roster not on file (See LIC9102)
· Documentation of fire and disaster drills on file – Last drill conducted on 01/20/2024
· Children’s records not are complete (See LIC809-D)
· 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 on 02/09/2024 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 your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with Licensee, Amy Dong 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 Licensee, Amy Dong 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.

Report Continued On LIC809-C
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173
VISIT DATE: 02/09/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

- Licensee, Amy Dong 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:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.

LPA Taityana Benson informed Licensee, Amy Dong that this report dated 02/09/2024 document(s) (1 Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.





Report Continued On LIC809-C
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DONG FAMILY CHILD CARE
FACILITY NUMBER: 364846173
VISIT DATE: 02/09/2024
NARRATIVE
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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.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Also, LPA Taityana Benson informed the Licensee, Amy Dong to provide a copy of this licensing report dated 02/09/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Licensee, Amy Dong, 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, Amy Dong.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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