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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191803292
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:55:21 AM


Document Has Been Signed on 10/26/2022 11:55 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:NICHOLS FAMILY CHILD CAREFACILITY NUMBER:
191803292
ADMINISTRATOR:DOROTHY NICHOLSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 754-0504
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:12CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Dorothy NicholasTIME COMPLETED:
11:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Doris Whitmore conducted an unannounced annual random inspection to ensure the health and safety of the Child Care Home according to Department Regulations & Safety Codes
LPA met with licensee, Dorothy Nichols, who guided analyst on a tour of the facility. At the time of the inspection there were currently no children in care. Licensee was the only adult present in the home. The home was inspected as follows: kitchen, living room, 3 bedrooms, 2 bathrooms, dining room, den, front yard and backyard. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The licensee states there are no weapons or firearms of any kind in the facility at this time. The LPA did not observe any weapons in the home. There is no pool, spa or other bodies of water on the premises. There are age-appropriate toys and equipment on the premises. The required fire extinguisher (2A 10BC) and smoke detectors are in operable condition. At the time of the inspection there was no carbon monoxide in the home. LPA checked a Fully stocked First Aid Kit. The den (play-area) was inspected for safety. On the Board Form LIC9148 Earthquake Preparedness Form was missing.

Areas off limits include: Kitchen, garage, 2 rear bedrooms and rear bathroom Rooms/ Areas were made inaccessible by: Kitchen with a child proof gate all other have doorknob locks. LPA checked a total of five children files only one file was missing the immunization record. LPA reviewed licensee documentation CPR/ First Aid completed 07/16/2022 Mandated Training date completed 06/06/2021. Licensee did not have documentation to show of immunization record, or Preventative Health & Safety Training Certificate.

The following was thoroughly discussed with the licensee:
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. Incidental Medical Services Include:
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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Document Has Been Signed on 10/26/2022 11:55 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: NICHOLS FAMILY CHILD CARE
FACILITY NUMBER: 191803292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 1] out of [1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licenses stated that she will have the carbon monoxide installed and willl take picture and email documentation
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1] out of [1 ] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licenssee stated that she will go to the doctor to get a copy of her immunization record and email documentation

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/26/2022 11:55 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: NICHOLS FAMILY CHILD CARE
FACILITY NUMBER: 191803292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 1] out of [1t]which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee stated that sghe will take the Preventative Heaklth and Safety Class with the information that was given on flyer and email certificate.
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 on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1] out of [total count] 1] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee stated that she will be going to the doctor on 10/27/2022 and will get copy of immunization record and will email documentation

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NICHOLS FAMILY CHILD CARE
FACILITY NUMBER: 191803292
VISIT DATE: 10/26/2022
NARRATIVE
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Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Carrying out medical orders when the child’s physician has determined that a layperson can be trained and safely carry out the order` Licensee was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-154. At this time, the facility does not provide Incidental Medical Services – IMS


Licensee was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov
Licensee was reminded it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care

Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis, and measles. Waiver for influenza was discussed during the inspection.

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into childcare or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NICHOLS FAMILY CHILD CARE
FACILITY NUMBER: 191803292
VISIT DATE: 10/26/2022
NARRATIVE
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Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each childcare center or family childcare home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university

Assembly Bill 1207: California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com

The following was discussed with the licensee:


All adults living and working in the home must be fingerprinted and cleared prior to entering the facility. The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.
· Entrance Checklist- Family Child Care Homes
· Preventative Health & Safety Flyer
· Fire Drill Form to document Fire drills
· Prohibited items in Family Child Care homes
· Forms Records to keep in your Family Child Care Home (LIC311D)
· L.A. County Public Health Customer Support for Blue Cards (323) 869-8080
· Community Care Licensing Address 300 Continental Bllvd#290A, El Segundo, CA 90245

There were deficiencies cited during today's 10/26/2022 visit. An exit interview was conducted, and a copy of this report was given to licensee Dorothy Nicholas.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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