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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700223
Report Date: 10/11/2021
Date Signed: 10/11/2021 03:25:29 PM

Document Has Been Signed on 10/11/2021 03:25 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:THOMAS FAMILY CHILD CAREFACILITY NUMBER:
367700223
ADMINISTRATOR:SAMIYA THOMASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 947-6494
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
10/11/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Samiya ThomasTIME COMPLETED:
03:40 PM
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Licensing Program Analyst's (LPAs) Thompson-Miller and Ibitoye conducted an inspection with Applicant Samiya Thomas who guided analyst's on a tour of the facility for a Prelicensing Inspection. This is a two story home with 4 bedrooms, 3 bathrooms, one office, kitchen/dining, living room, den, laundry room, patio and detached garage. There is no pool/or body of water on the premises. Family members residing in the home include two adults (Applicant, adult male friend) and four children. Applicant is a Foster Parent (will email copy of license). Days/hours of operation will be Monday through Friday from 6:00AM to 6:00PM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Home is clean and orderly, fireplace is screened, age appropriate toys and play equipment, working smoke detector and carbon monoxide detector, operable Fire Extinguisher (2A10BC), 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, off limit areas include the entire upstairs, two working phones (one personal, one for the home), poisons and cleaning items inaccessible to children. Laundry (adjacent to the kitchen) is off limits. There are two dogs (one is outside, one is inside).

Kitchen/bathroom: The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Sharp items (knives upper kitchen cabinet in a lock box), medication (upstairs off limits room, lockbox in the refrigerator) and chemicals (located in upper kitchen cabinet) are inaccessible. Toilets and faucets are clean and operable and home has a clean fully stocked of food refrigerator/freezer.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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: THOMAS FAMILY CHILD CARE
FACILITY NUMBER: 367700223
VISIT DATE: 10/11/2021
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Outdoor: The area of the backyard used for child care is fenced (wood) and gated. This play area is clear and clean of debris. There is a covered patio, refrigerator with a safety latches, two barbecue grills with cover, neighbor home behind the house has an empty in-ground pool. Applicant shall ensure children are supervised during outside play.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 09/18/2023. Preventative Health and Safety (Nutrition, Lead Poisoning) 09/24/2021. The electrical outlets are covered. Children nap on cots, there is cushioning material in the play area. There are cordless window coverings.
Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.
Documents Provided and or Discussed: The following was discussed to be in regulation of Title 22 requirements: Seat Belt Safety, Safe Sleep poster observed, Notification of Parents' Rights.

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 Applicant:


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; Licensee were reminded that 100% supervision is required at all times to children in care; Licensee were 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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: THOMAS FAMILY CHILD CARE
FACILITY NUMBER: 367700223
VISIT DATE: 10/11/2021
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Applicant was 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.

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 child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The Applicant 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.

Before licensure the following must be completed:


1. The laundry room shall be inaccessible
2. Plastic bag under the kitchen sink shall be inaccessible

Once 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.
Exit interview conducted and a copy of this report was read and provided to Applicant Samiya Thomas.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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