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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197402897
Report Date:
07/01/2022
Date Signed:
07/04/2022 08:37:46 PM
Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
ADMINISTRATOR:
SHEPHERD, MYRA A.
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(323) 777-6395
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90047
CAPACITY:
14
CENSUS:
6
DATE:
07/01/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Myra Shepherd
TIME COMPLETED:
04:45 PM
NARRATIVE
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On July 1, 2022, Licensing Program Analyst (LPA), Veronica Wheatley conducted an unannounced Annual Required Inspection and met with the licensee Myra Shepherd at 1:00PM. The licensee's assistant Jessica was also present. There are 6 day care children present today. LPA observed 4 children napping downstairs and 2 children napping upstairs. The hours of operation Monday through Friday, 6am and 6pm.
LPA toured the home inside and out and took a census was taken of 6 day care children. Current facility sketch reviewed and confirmed that the living room and one bedroom downstairs is used for providing care and is accessible to children. However, LPA observed two children over age 2 napping upstairs in two separate bedrooms. There is no swimming pool or other bodies of water on the premises. Per licensee, there are no firearms or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible with child proof locks in the kitchen and main bathroom. There is a working fire extinguisher, smoke detector, carbon monoxide and adequate ventilation for safety and comfort. According the licensee, there is central heating and air condition. Safe toys and play equipment are observed. The home has a working telephone.
LPA discussed Safe Sleep Regulations with licensee. Cribs and play yards will be 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 will physically check on sleeping infants every fifteen minutes and document 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. 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
SUPERVISOR'S NAME:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
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
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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:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
VISIT DATE:
07/01/2022
NARRATIVE
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Licensee ensures 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 states she does not transport and children. LPA informed licensee that written approval from the parents or authorized representative in order to transport children. Capacity as specified on the license is being maintained. The outdoor play area in the backyard is fenced. The yard is clean and safe. There are dogs kept inaccessible to children and no bodies of water.
LPA reviewed a sample of children’s files and observed files were incomplete with missing documents. Licensee’s and assistant do not have CPR and first aid. A review of records indicates that all employees and/or volunteers do not have immunization records on file for influenza, pertussis and measles.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. 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 discussed with the licensee the Community Care Licensing website
www.ccld.ca.gov
. Licensee states she is receiving the 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.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies are cited.
Exit interview. A copy of this report was provided to the licensee today.
SUPERVISOR'S NAME:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
2
of
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Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/01/2022
Plan of Correction
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2
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4
Licensee removed all items from bathroom and kitchen during the inspection.
Type B
Section Cited
CCR
102417(g)(9)(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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2022
Plan of Correction
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2
3
4
Licensee will create a fire drill log and submit proof of correction to the department by 7/5/2022
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.
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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/01/2022
Plan of Correction
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Licensee will ensure that there are no items in a crib or playpen. The licensee removed all blankets from the play pens during the inspection
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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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/15/2022
Plan of Correction
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Licensee will submit her immunization records for herself and her daughter Jessica Shepherd
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/15/2022
Plan of Correction
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Licensee will have herself and daughter (assistant) complete CPR and first aid by 7/15/2022
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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/15/2022
Plan of Correction
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2
3
4
Licensee will provide
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).
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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/08/2022
Plan of Correction
1
2
3
4
Licensee will have the children's files completed with all required forms by 7/8/2022
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/08/2022
Plan of Correction
1
2
3
4
Licensee will have the children's files completed with all required forms by 7/8/2022
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2022
Plan of Correction
1
2
3
4
Licensee will complete the Children's Roster by 7/5/2022 and submit to the Department
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
8
of
8
Document Has Been Signed on
07/04/2022 08:37 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
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
SHEPHERD FAMILY DAY CARE
FACILITY NUMBER:
197402897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/08/2022
Plan of Correction
1
2
3
4
Licensee will have the parents complete forms by 7/8/2022
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:
Maureen Neal
TELEPHONE:
(424) 301-3042
LICENSING EVALUATOR NAME:
Veronica Wheatley
TELEPHONE:
(424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
LIC809
(FAS) - (06/04)
Page:
7
of
8