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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700280
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:38:14 PM

Document Has Been Signed on 08/26/2022 12:38 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:WALLER FAMILY CHILD CAREFACILITY NUMBER:
367700280
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
08/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Shavonda WallerTIME COMPLETED:
01:05 PM
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Licensing Program Analysts (LPA) Babatunde Ibitoye conducted an announced visit with Applicant Shavonda Waller who guided analyst on a tour of the home for a Pre licensing Inspection for a small family childcare home. This is a two- story home with 5 bedrooms, 3 bathrooms, kitchen/ dining room, living room, family room, laundry room and attached garage. There is no pool/or body of water on the premises. Family members residing in the home include one adult (Applicant) and five minor children. Days/hours of operation will be Monday through Sunday from 6:00 AM to 9:00 PM.

Physical Plant: Home is clean and orderly, there is a fireplace in the family room which is inaccessible to children with a glass barrier locked. LPA's observed age appropriate toys and play equipment, working smoke detector and carbon monoxide detector, and fully charged 2A10BC Fire Extinguisher. Per applicant no one smokes in the home. There is a designated area for ill child(ren) as necessary, no weapon/firearms, facility sketch complete and current, Applicant states living room upstairs, family room downstair , kitchen/ dinning, bathroom #1,#2 , backyard is utilized for the family childcare, off limit areas include all of the homes bedroom #1-#2-#5, bathroom #3 inaccessible with a child gate , laundry room inaccessible with door locked, living room#1 down stairs and garage inaccessible with door locked. The stairs is made inaccessible by child gate. There is a working telephone (cell phone), poisons and cleaning items inaccessible with a safety latches (under the sink kitchen cabinet) to children.

Kitchen/bathroom: The following are inaccessible: Sharp items (under kitchen counter in a cabinet), medications (under kitchen cabinet) and chemicals (laundry room) (off-limits) are inaccessible. Toilets and faucets are clean and operable.

Outdoor: LPA's observed the homes backyard. The backyard is safe for children, LPA observed two storage with bicycle gardening tools). The two storage are made inaccessible with lock, LPA Observed a small dog inaccessible in cage locked, per applicant all the shots records are up to date, LPA Observed Air condition units inaccessible with tared plastic cover. The outdoor play shall be supervised by the applicant.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 08/26/2022
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The area of the backyard used for childcare is fenced (wood wall) and gated. This play area is clear and clean of debris. LPA's did not observe any items that could be hazardous to children in care.

Advisory/Other: First Aid kit readily available. CPR/First Aid expire 04/13//2024. The electrical outlets are covered. LPA's observed 1 crib, 4 mat and 1 cot for children/infants to nap. Per licensee the children will nap in the day-care room (living room upstairs). Applicant reminded to supervise children at all times.

Pets: Per applicant there are pets in the home Always outside in the backyard. LPA's observe one dog in the locked cage and one cat in the backyard during the pre-licensing inspection.

LPA advised Applicant All adults living/residing in the home are fingerprint cleared and associated.

Documents Provided and or Discussed: The following were discussed regarding Title 22 requirements: Safe Sleep and Small Family Child Care Home Ratios

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

The following was discussed with the Licensee/Applicant: Safe Sleep and Small Family Child Care Home Ratios

Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Applicant reminded that 100% supervision is required at all times to children in care; Applicant made aware that it is her/their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care.

Applicant advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The applicant was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 08/26/2022
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Applicant advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

At this time the facility is in Compliance with Title 22 regulations and LPA Ibitoye will submit the proper documentation and information to request the facility to be issued a Small Family Child Care License.




Exit interview conducted and a copy of this report was given to Applicant Shavonda Waller.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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