191594940-5-3-2022-54-CC-RRAS-CE3SKL-20220503135656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191594940
Report Date: 05/03/2022
Date Signed: 05/03/2022 01:57:24 PM

Document Has Been Signed on 05/03/2022 01:57 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	COLBERT FAMILY DAY CARE		FACILITY NUMBER:	191594940
ADMINISTRATOR:	COLBERT, LEE ETTA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 213-9767
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	14	CENSUS: 10	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Lee Etta Colbert, Licensee		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rita Ramos conducted an unannounced required 1 year inspection to the above facility on 05/03/22. LPA arrived at the facility at 9:35AM, identified self and met with Lee Etta Colbert, Licensee who guided analyst on a tour of the facility. LPA provided Licensee with a copy of the LIC 126 Entrance Checklist to help facilitate the inspection. LPA observed that also present during this inspection, was Menali Porchia Licensee’s Assistant. LPA observed 9 children upon arrival. Co-Licensee Hyacinth Colbert, arrived after LPA and LPA Ramos met with them as well. Per Licensees, operation hours are Monday through Friday from 6:30AM to 6:00PM. A 10th child arrived during the inspection. Per Licensees there are 12 children that are currently enrolled. A current children’s roster was not available for review during the inspection. This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining area, living room, play room, front yard, backyard (fenced), and a pool. The children use the bathroom in the hallway. At approximately 10:08AM LPA observed that there is a fireplace in the living room and it is not barricaded or latched. Per Licensee, areas off limits to children and parents include: 2 bedrooms, the garage, and the pool area. The licensee provides food for children in care. Individuals who reside in the home were noted and discussed. Per Licensee, they currently have one assistant. Licensees were 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 ----Page 1 of 5

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
	VISIT DATE: 05/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the inspection LPA informed Licensees that Menali Porchia is not associated to the facility. Per Menali Porchia they are new and just started working at the facility last Thursday (April 28, 2022). A civil penalty of $400 is being assessed during today's visit.

Licensee states that there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a landline and a cellphone. There is ventilation and heating. At approximately 9:44AM LPA observed that the vent on the floor and wall has a broken screen. Safe toys play equipment and materials were observed.

Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. Per Licensees, there are no poisons stored in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.

The valve on the required 2A 10BC fire extinguisher was observed to not have a receipt or a Fire Marshal tag. Smoke and carbon monoxide detectors were tested during the inspection to ensure that they are operable.

Licensee is currently caring for infants. After LPA conducted a child records review at approximately 10:57AM, LPA noted that 7 of the 10 children present are infants (under the age of 2). LPA discussed license limitations with the Licensees and noted that their license notes that there cannot be more than 4 infants present or in care. The Licensees were over capacity during the inspection. Licensee states that infants sleep in one of the bedrooms (infant room) where they are constantly supervised. At approximately 9:53AM LPA observed Child #2 asleep on a play yard wearing a bib and there was a toy hanging above the play yard. LPA advised the Licensee about the the Provider Information Notice (PIN) 20-24 CCP: Recently Approved Safe Sleep Regulations in Effect and provided a copy. LPA advised that mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards shall also be free of loose articles and objects. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. -----Page 2 of 5

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
	VISIT DATE: 05/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee due to Licensee not having an LIC 9227 completed for Child #2.

LPA discussed the safe sleep regulations with licensees 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 [facility representative] 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.

Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did observe a pool in the backyard with a gated door that opens in but the door is no longer self-latching and did not have a lock. Licensee placed a lock during the inspection. Licensees stated that the department granted a waiver for the pool dated 05/28/10. LPA observed that the waiver for the pool was posted. The licensee states that supervision is always provided.

The licensee and other personnel have completed Pediatric First Aid and CPR. The licensees Pediatric First Aid and CPR expires on 07/14/23.

Children’s records were reviewed, LPA went over forms and documentation missing.

The licensees do not have proof of immunization against influenza, pertussis, and measles.

LPA observed that one of the Licensees do not have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file.

----------Page 3 of 5

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 3 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
	VISIT DATE: 05/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA issued a Confidential Names List (LIC 811) to the licensees which documents staff and children’s files reviewed during this inspection.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Licensees did not have a drill log documented during the inspection.

Emergency Disaster Plan and Parent’s Rights Poster were not observed to be posted.

LPA did observe items baby walkers and bouncer chairs during the inspection, however, did not see any children using the items. LPA advised that no Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

The following deficiencies listed on the attached deficiency pages are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. LPA: add if a type a deficiency is cited
----Page 4 of 5

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 4 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
	VISIT DATE: 05/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee/Director.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Hyacinth Colbert.

----Page 5 of 5

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 5 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

102370(d)(2)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above due to Assistant Menali Porchia not being associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty of $400 is being assessed during today's visit.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Per Licensee, assistant will submit fingerprints this week and be associated by POC due date.

Type A

Section Cited

CCR

102416.5(d)(1)

Staffing Ratio and Capacity

(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above due to having 7 infants in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Per Licensee, they will make 3 of the infants part time so that there are no more 4 infants in care by POC due date.

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 6 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above due to having a wall and floor vent that has a broken screen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2022
	Plan of Correction
1 2 3 4	Per Licensee, a screen will be ordered and fixed by POC due date.

Type B

Section Cited

CCR

102417(g)(1)

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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above due to LPA observing the the chimney does not have a barricade or lock to prevent a child from opening it which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Per Licensee, a barricade was ordered and will be placed by POC due date.

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 7 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(b)(3)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above due to play yards having loose articles, and objects which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Per Licensee, all loose items will be removed from play yards by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 8 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(5)(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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above due to LPA observing that the pool door was not locked and it opens toward the pool. LIcensee noted that they have a waiver on file fo the pool and it doesn't expire. LPA informed Licensee that waivers can stand if all items noted are in compliance or if the department notices concerns and the gated door has no lock, no alarm, and opens toward the pool which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2022
	Plan of Correction
1 2 3 4	Per Licensee, the gated door leading to the pool was locked during the inspection.

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 9 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above due to not having any documentation or log indicating that infants are being checked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Per Licensee, they have a log created but will keep it current by POC due date.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,i nterview and ecord review the licensee did not comply with the section cited above due to Licensee not having immunization records on file for Child # 2, #3, #9, and #10 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2022
	Plan of Correction
1 2 3 4	Per Licensee, immunization records will be requested and placed in the file by POC due date.

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 10 of 11

Document Has Been Signed on 05/03/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COLBERT FAMILY DAY CARE	FACILITY NUMBER: 191594940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above due to not having records of immunization for Licensees and assistant, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Per Licensee, copies will be available in the file for review by POC due date.

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above due to not having any roster for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Per Licensee, a completed roster will be avaolable by POC due date.

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: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 11 of 11