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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700284
Report Date: 08/24/2022
Date Signed: 08/30/2022 09:40:59 AM

Document Has Been Signed on 08/30/2022 09:40 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GREEN FAMILY CHILD CAREFACILITY NUMBER:
367700284
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
08/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:46 AM
MET WITH:Kina and Kynunula Green ApplicantsTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Steven Montoya met with Applicant, Kina and Kynunula
Green, who guided analyst on a tour of the Green Family Child Care Home for a Prelicensing Inspection. This is a single story 3 bedroom, 2 bathroom home with kitchen/dining, family room, living room, bonus room, (laundry) garage. There is no pool/spa or body of water on the premises. Family members residing in the home include 2 adult (applicant) and 2 children (15 and 16 years of age). Days/hours of operation are Monday through Sunday 4 AM to 3 AM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the living room (at entrance). Children use the bathroom in the hallway on the Right. Off limit areas include all Bedrooms (#1 , #2 , #3, bathroom #2), pantry, laundry in garage (lock). The hallway is off limits. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (garage and laundry), medicines (off limits main bedroom) and hazardous items (sharp knives inside kitchen cabinet, tight fitting container) that can pose a danger to children.

There are one fireplaces (one in family room with a glass screened) which was not locked. There are safe age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector was tested. Fire Extinguisher (2A10BC) are in operable condition. Per Applicant no one smokes in the home.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 08/24/2022
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Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/play equipment were observed on the premises. There is a designated area for ill children as necessary in living room. Per Applicant there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell 760 514-2227). LPA explained to conduct Fire/earthquake drills every six months and document. LPA provided the Roster and explained how to complete and maintain current. Age appropriate napping (cots, playpen) equipment.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Applicant shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.



Applicant 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.

LPAs discussed the safe sleep regulations with Applicant Kina and Kynunula and discussed the Child Care Licensing Safe Sleep webpage as an additional resource. LPA also informed Kina and Kynunula 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: Claretta Yates
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 08/24/2022
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Before licensure the following must be completed:
1. None

A notice of site visit was provided. Applicant was advised at the Regional Office (Palmdale) Duty Worker is available for questions Monday through Friday 8am to 5pm @
(661) 202-3318.

Exit.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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