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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805900
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:43:59 PM


Document Has Been Signed on 02/16/2023 02:43 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:GREEN-SIMMONS, JASMINE FAMILY DAY CAREFACILITY NUMBER:
191805900
ADMINISTRATOR:GREEN-SIMMONS, JASMINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 766-0227
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY:12CENSUS: DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:GREEN-SIMMONS, JASMINE, LicenseeTIME COMPLETED:
02:55 PM
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On 02/16/23, at 8:29 AM, Antonio Almanza, Licensing Program Analyst (LPA), conducted an unannounced Annual Required Inspection and was met by Jasmine Green-Simmons, Licensee. Days and hours of operation are Monday through Saturday 6:00 AM to 6:00 PM. The licensee is the only person living in the home. Licensee does not currently have children in care.

LPA toured the home inside and outside. The home is a single-story home with 2bd, 1 bathroom, dinning room, kitchen, laundry room, and den. Licensee utilizes the living room, dining room and bathroom for children in care. The 2 bedrooms, kitchen and den are off-limits to children. The kitchen is adjacent (left side) to the dining room (children's area) and is made inaccessible by a locked door. The hallway to the bedrooms and bathroom has a half door that is kept closed and only opened when children go to the bathroom. Bedrooms are kept locked while children are in care.

The back yard is covered with grass and is used for children in care. There is a block wall and fencing in the back yard. There is a spa in the back yard with hard cover and latches. Licensee states there are no firearms or ammunition on the premises, LPA did not observe any. All poisons are kept in a locked storage area. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. Licensee does not have required posting PUB394 Notification of Parents Rights and LIC9148 Earthquake Preparedness.

There is a fireplace located in the living room made inaccessible by a book case and wooden board and will not be in use during daycare hours. There is a working smoke detector (living room/dinning room), carbon monoxide detector (dinning room) and adequate heating and ventilation (window AC/Heater) for safety and comfort. Licensee has a Fire Extinguisher (2A10BC) in the kitchen that was purchased 2 years ago and has not been serviced. First aid Kit is kept in the hallway of the home. There are no stairs in this home. The home has working land line telephone service.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN-SIMMONS, JASMINE FAMILY DAY CARE
FACILITY NUMBER: 191805900
VISIT DATE: 02/16/2023
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There are currently no infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider was reminded that they shall physically check on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Licensee was reminded that Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee was reminded that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Licensee was reminded that a children's roster must be maintained when children are in care. Emergency fire/disaster drills must be completed and documented every 6 months. Licensee does not have a current Mandated Reporter Training Certificate on file. Licensee’s pediatric CPR/First Aid expires on 06/05/23.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.


LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

LPA provided licensee with and reviewed LIC311D Forms/Records to Keep in your Family Child Care Home, and Safe Sleep Pin 20-24-CCP.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN-SIMMONS, JASMINE FAMILY DAY CARE
FACILITY NUMBER: 191805900
VISIT DATE: 02/16/2023
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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/process.

Licensee 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.

LPA discussed the safe sleep regulations with licensee [or facility 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.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following 2 Type B deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.
1. 1596.8662(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
2. 102417(g)(1) Operation of a Family Child Care Home, 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 Marshal.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Jasmine Green-Simmons.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 02/16/2023 02:43 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: GREEN-SIMMONS, JASMINE FAMILY DAY CARE
FACILITY NUMBER: 191805900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that the licensee does not have current Mandated reporter Trianing on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Licensee wil complete Mandated Reporter Training and provide LPA a copy by 02/24/23.
Type B
Section Cited
CCR
102417(g)(1)
102417(g)(1) Operation of a Family Child Care Home, 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 Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the fire extinguisher was purchased 2 years ago and has not been serviced, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will purchase or have the Fire Extinguisher serviced by 02/17/23.
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: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6