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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407811
Report Date: 03/28/2022
Date Signed: 03/28/2022 06:30:41 PM


Document Has Been Signed on 03/28/2022 06:30 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:PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.FACILITY NUMBER:
197407811
ADMINISTRATOR:PEGGY & PENNY NAIRNFACILITY TYPE:
850
ADDRESS:15300 DEARBORNTELEPHONE:
(818) 892-6635
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:25CENSUS: 10DATE:
03/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Director Gloria AvinaTIME COMPLETED:
06:45 PM
NARRATIVE
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On 03/28/2022 at 8:28 a.m., Licensing Program Analyst (LPA) Antonio Almanza conducted an unannounced Case Management Visit at the Probationary Licensed Facility. During today’s visit LPAs met with the Director, Gloria Avina, explained the purpose of the visit and toured that facility. During today’s visit there were 1 adults providing care and supervision to 4 children in care.

The Director is reporting that the Dearborn preschool License location operates Sunday through Monday from 8:00 a.m. to 5:00 pm when the remaining children (approximately 5 children) are taken to the Columbus preschool FAC# 197407318. All Adults in the facility have received criminal record clearance but are not associated to the facility. Prior to entering the facility, LPA Almanza attempted to conduct a COVID-19 Risk Assessment by calling the facility phone number 3 times, but no one answered the phone.

During todays visit the following violations are being cited:
1. LPA attempted to verify the facility phone number (818) 892-6635 was correct and operating LPA was not able to verify the phone was operating or the phone number is correct. Director states the phone number on file belongs to the Columbus location. It was explained to the Director, the importance of the facility having a functioning phone and staff attending to the phone, because the call may be related to an emergency that can affect the Health and Safety of Children in Care.

2. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, Staff 1 (Gloria Avina) is the Director of the Dearborn Child Care Center location Monday through Saturday from 6:00 a.m. to 3:00 pm. Based on the Documents provided by Peggy Nairn, Staff 1 does not have the qualifications required to be the Director.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811
VISIT DATE: 03/28/2022
NARRATIVE
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3. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, there is no Director scheduled at the Dearborn location Sunday through Saturday 9:00 p.m. to 6:00 a.m., and Sunday 6:00 a.m. Based on the Application for Child Care Center submitted by the Peggy, The facility is operating 24-hrs per day 7 days per week.

4. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn and the information provided by staff, the persons assigned as the child care center directors during the evening, and night programs are assigned classroom teachers. There is no Actual Director on site during these times. The evening and night and night time Directors are assigned to classrooms as teachers when they are supposed to be the Director.

5. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn, Licensee has not provide 24 hours of quarterly training to staff on mental health assessments, client behaviors, personal rights, care and supervision, and medication and keep a record of staff who attend such training and make records available to Licensing.

6. Per Stipulation Waiver; and Order no staff shall work more than 8 hours per day, Based on information provided by Facility Staff, they have been working over 8 hours per day.

7. LPA did not observe Personal Rights Form LIC-613A, posted in a location were parents in the Child Care Center can see them. The Notice has this LPAs contact information and does not have the El Segundo Regional Office telephone number.

8. LPA did not observe Child Care Center Notification of Parents' Rights Poster PUB 393, posted in a location were parent in the Child Care Center can see them and the item that is posted inside the facility is blocked a a large pot and plant, were parents do not have access. The Notice has this LPAs contact information and does not have the El Segundo Regional Office telephone number.

9. LPA did not observe the Child Care Center license in area where parents can see it during pick up and drop off.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811
VISIT DATE: 03/28/2022
NARRATIVE
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10. Per records review and information provided by staff children that are enrolled at this location are taken every day to the Columbus location around 5:00 p.m. or 6:00 p.m. until they are picked up by their parents.

11. During todays visit, the toilets in the children’s restroom were clogged and not working. Director states that when she started her shift today at 6:00 a.m. the toilets were not working; she called the plumber and the plumber arrived around 1:15 p.m. Director states she does not know when the toilets were clogged and that she was not at work yesterday nor was she notified.

12. LPA observed the playground has 6 trees with artificial turf around them and circular barrier at the base that creates a step into the dirt around the trees. This posses a potential risk to children stepping onto this area and possibly injuring themselves.

13. On the walkway that children take to the playground LPA observed boxes, bins, buckets, play equipment, planters, rugs, stacked concrete pavers, chairs and other miscellaneous items stacked Infront and around the storage building. The items appear to be full of spider webs and dust/dirt. This are is accessible to children as they walk to the playground and may pose a health and safety risk to children in care.

14. LPA observed food in the refrigerator that was expired: mayonnaise, Sour Cream, and container of shredded chicken that was not labeled. Director states the chicken was from the weekend.



15. During todays visit LPA observed Staff 2 supervising children in care. Staff two has a criminal record clearance but is not associated to the facility. LPA asked the Director is she had access to guardian and the she stated no.

During today’s visit the following violations are being cited under Title 22 Regulations, Division 12, Chapter 1, of the California Code of Regulations, and Health & Safety Code. There are two (3) Type A violation and thirteen (10) Type B violations (please see LIC 809-D for cited deficiencies).

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811
VISIT DATE: 03/28/2022
NARRATIVE
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During today’s visit 2 Civil Penalties for repeat violations were issued on LIC421FC; And One civil penalty for LI

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of LIC 9224 was provided to Director.

A copy of this Report (809 &809D) and appeal rights were explained and provided to the Director Gloria Avina. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.






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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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101215.1(h)(1) Child Care Center Directors Qualifications and Duties, High school graduation or GED; completion, with passing grades, of 15 semester or equivalent quarter units as specified in (h)(1)(A) and (h)(1)(B) below at an accredited or approved college or university...
This requirement is not met as evidenced by:
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Based on records review, Staff 1 does not have the qualifications to be Director, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited

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101215.1(d) Child Care Center Directors Qualifications and Duties, The child care center director, or the substitute director as specified in (f) below, shall be on the premises during the hours the center is in operation.
This requirement is not met as evidenced by:
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Based on observation and records review, The Licensee does not have a Director assigned to the Facility During all hours of operation, which poses a potential Health or Safety, or personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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101215.1(c) Child Care Center Directors Qualifications and Duties,The child care center director shall be responsible for the operation of the center, for compliance with regulations, and for communications with the Department...

This requirement is not met as evidenced by:
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Based on interviews, The Licensee does not have a Director During the Evening and Night progrmas, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
03/28/2022
Section Cited

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101216(e)Personnel Requirements, All personnel shall be given on-the-job training... Per Stipulation Licensee shall provide 24 hours of quarterly training and keep a record of staff who attend such training and make records available to Licensing.
This requirement is not met as evidenced by:
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Based on observation and records review, The Licensee does not have records available for the 24 hours of quarterly training, which poses a potential Health or Safety, or personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 6 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited

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101216(l) Personnel Requirements (l) All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code.
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Based on records review staff have been working more than 8 hours, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Director will provide LPA with copy of the staff time cards from 03/01/2022 to 03/25/2022 and provide a Mitigation Plan demonstrating how the facility will ensure to be fully staffed at all times and that no employee shall work more than eight (8) hours per day by end of day 4/01/22
Type B
04/01/2022
Section Cited

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101223 Personal Rights (b)(2) The center shall post a copy of the LIC 613A (9/96) in a prominent, publicly accessible area in the center.
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Based on Observation a copy of the LIC 613A is not posted in a prominent, publicly accessible area of the center, which poses a potential health, safety or personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 7 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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101218.1 Admission Procedures and Parental and Authorized Representative's Rights
(c) The licensee shall post the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster in a prominent, publicly accessible area in the child care center at all times.
This requirement is not met as evidenced by:
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Based on Observation a copy of the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster is not posted in a prominent, publicly accessible area of the center, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited

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101238 Buildings and Grounds, (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
This requirement is not met as evidenced by:
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Based on Observation the toilets in the childrens restroom was in disrepair from 6 am until about 2:00 pm when it was fixed, which poses a potential health, safety or personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 8 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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101238.2 Outdoor Activity Space (d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.
This Requirement is not met as evidenced by:
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Based on observation LPAs observed two trees with a circular barrier lower than the turf around, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited

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101238 Buildings and Grounds (d) General permanent or portable storage space shall be available for the storage of the center's equipment and supplies.
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Based on observation LPA observed the area on the walkway in front of storage building with stacked miscellaneous items, which poses a potential Health or Safety, or personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 9 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited

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Food Services 101227(a)(19)
All food shall be protected from contamination. Contaminated food shall be discarded immediately.
This requirement is not met as evidenced by:
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Based on LPA observations there was expired food in the refrigerator, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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Type A
03/28/2022
Section Cited

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101170(e)(2) Criminal Record Clearance, (e) All individuals subject to a criminal record review... (2) Request a transfer of a criminal record clearance as specified in Section 101170...
This requirement is not met as evidenced by:
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Based on LPA observations and records review, Staff 2 is not associated to the facility and has been working since November 20221, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 10 of 11


Document Has Been Signed on 03/28/2022 06:30 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2022
Section Cited

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101224(a) Telephones, All child care centers shall have working telephone service on the premises.

This requirement is not met as evidenced by:
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Based on LPAs observations and information provided the facility does not have a working phone, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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