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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403006
Report Date: 11/14/2019
Date Signed: 11/14/2019 01:52:56 PM

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:OLMSTEAD FAMILY DAY CAREFACILITY NUMBER:
197403006
ADMINISTRATOR:OLMSTEAD, MAY A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 385-1147
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:14CENSUS: 3DATE:
11/14/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:May OlmsteadTIME COMPLETED:
02:30 PM
NARRATIVE
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Margarit Sislyan, Licensing Program Analyst (LPA) conducted a case management visit on 11/14/19. LPA met with licensee, May Olmstead.

LPA discussed the reporting requirements with Licensee.

Licensee failed to report the incident occurred on 10/30/19 that three year old day care child wandered away.

Licensee was cited Type B deficiency, according to California Code of Regulations Title 22 See 809D report for deficiencies.

Exit interview

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: OLMSTEAD FAMILY DAY CARE
FACILITY NUMBER: 197403006
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2019
Section Cited

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The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
Any child absence means any instance where a child in care is missing.
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For example, any child in care who wanders away from the Family Child Care Home.

This requirement is not met as Licensee did not report to CCLD that day care child wandered away from FCC on 10/30/19.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2