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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197408924
Report Date:
11/18/2022
Date Signed:
11/18/2022 04:34:13 PM
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
ADMINISTRATOR:
BRENDA BROOME
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(310) 706-1443
CITY:
COMPTON
STATE:
CA
ZIP CODE:
90222
CAPACITY:
14
CENSUS:
3
DATE:
11/18/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:45 PM
MET WITH:
Licensee Brenda Broome
TIME COMPLETED:
04:50 PM
NARRATIVE
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On 11/18/22 at 12:45 PM Licensing Program Analysts (LPAs) Austin Estrada and Jeanette Estrada conducted an unannounced required 1 year inspection at the above facility. LPAs met with the Licensee Brenda Broome and informed her of the purpose for the visit. Licensee guided LPAs on a tour of the facility. There were 3 children present when LPA arrived. A fourth child arrived at a later time. Criminal record clearance for all adults present was verified. Licensee provides care to children ages 1 year to 6 years old and operation days/ hours are Monday through Friday 6AM to 5PM.
This is a one story 3 bedroom 2 bathroom home with a living room, dining room area, kitchen, detached garage, and fenced backyard. Areas on limits to children are the living room, dining room, both bathrooms, one bedroom (infant room), kitchen, and fenced backyard. At the time of inspection, part of the backyard is not being used as it is undergoing a renovation. Areas off limits to children are two bedrooms, and detached garage. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPAs reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted in August 2022. There is an operable carbon monoxide detector and a smoke detector in the home. The 2A10BC Fire extinguisher in the laundry room indicated fully charged and was last serviced on 3/2020. LPAs advised Licensee to purchase a new fire extinguisher or get current one serviced as they are to be serviced yearly. The home maintains telephone service (mobile phone). Licensee provides breakfast, lunch, and snacks. Licensees were reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated. The home is observed to be clean and orderly. There are toys and other age appropriate materials available for children. LPAs observed two walkers in the day care room. LPAs advised the Licensee to remove the walkers as they are not allowed for child use. Licensee immediately removed the walkers and placed them in the inaccessible detached garage.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
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
13
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)
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:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a door leaning against the detached garage that had a protruding object coming through the door, paint thinner under plastic chair and feces on a child’s scooter in the accessibke area of the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2022
Plan of Correction
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2
3
4
Licensee will provide proof of removal of door leaning against the garage and removal of feces on the childs scooter via email.
Licensee removed paint thinner and painting materials during the inspection and placed them in the off limits garage.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
2
of
13
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having tricycles with spider webs on them, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/02/2022
Plan of Correction
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2
3
4
LIcensee will provide LPA proof of removal of sider webs via email.
Type B
Section Cited
CCR
102417(g)(1)
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: (1) 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 Marshall.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by not having a fire extinguisher serviced or purchased in the past year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/02/2022
Plan of Correction
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2
3
4
Licensee will provide proof of purchase or service of fire extinguisher to LPA via email.
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:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
3
of
13
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having two baby walkers in the day care room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/18/2022
Plan of Correction
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2
3
4
Licensee immidiately removed the walkers and placed them in the off limits garage during inspection.
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
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having toys and stuffed animals in the play yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/18/2022
Plan of Correction
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2
3
4
Licensee immediately removed all items from the play yards during the inspection.
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:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
4
of
13
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/18/2022
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having the mandated reporter training certificate for review at the time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/02/2022
Plan of Correction
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Licensee will provide proof to LPA of completed mandadted reporter training via email
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 record review, the licensee did not comply with the section cited above by not having proof of immunizations at the time of inspection which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/16/2022
Plan of Correction
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2
3
4
Licensee will provide proof of immunizations to LPA via email.
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:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
5
of
13
Document Has Been Signed on
11/18/2022 04:34 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
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 children did not have immunization records available at the time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/16/2022
Plan of Correction
1
2
3
4
Licensee will provide proof of childrens immunizations and completed file of all children enrolled at the facility to LPA via email.
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:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
10
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
VISIT DATE:
11/18/2022
NARRATIVE
1
2
3
4
5
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--pg 2--
Sharp objects, detergents and cleaning compounds are kept in the laundry room in an upper cabinet and a locked cabinet to the side of the washer and dryer and are inaccessible to children in care. Sharp objects such as knives are kept in an upper cabinet in the laundry room inaccessible to children in care.
Per Licensee there are no child who require medication. Per Licensee, personal medication is kept in an off limits bedroom. LPAs observed an air conditioning unit in day care room. LPA observed a wall heater in the day care room which was made inaccessible to children. LPAs observed a fire place in the living room which is inaccessible to children in care. Per Licensee, Children have meals in the infant room and day care room. Children have access to both restrooms in the facility. Per Licensee, children are supervised while playing outside. While touring the outside play area, LPAs observed tricycles to have spider webs on them, LPAs observed a door leaning against the detached garage that had a protruding object coming through the door, LPAs observed paint thinner under plastic chairs accessible to children in care and LPAs observed feces on a child’s scooter. Licensee immediately removed the paint thinner to the inaccessible detached garage.
LPAs observed poisons (Raid) in a upper cabinet located in the laundry area. LPAs advised Licensee that all poisons should be locked. Licensee immediately removed the Raid and relocated it to an inaccessible bedroom. Licensee understands that all poisons must be locked, not only inaccessible to children. Per Licensee, the Isolation area for sick children waiting to be picked up is in the infant room with adult supervision. Per Licensee, there are no firearms or weapons stored in the home. LPAs did not observe pools or spas, or other bodies of water.
Infant Care: Currently licensee cares for 2 infants. LPAs observed 2 play yards in the infant room. LPAs observed various toys and stuffed animals in each play yard. LPAs advised the Licensee to remove all items from the play yards. Licensee immediately removed all items from both play yards. Per Licensee, infants sleep in the play yard. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. Per licensee wet or soiled sheets are laundered in the facility. Each infant has their play yard and bedding. LPAs and licensee reviewed the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months. Licensee provides sleep mats for children in care.
Overnight Care: There is no overnight care provided at the moment. LPA discussed the following: Licensee is aware that they must remain wake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
11
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
VISIT DATE:
11/18/2022
NARRATIVE
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2
3
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5
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8
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--pg 3--
Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). 3 out of 4 children did not have any records during the inspection.
Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement of Child and Mandated Reporter Training Certificate. Licensee completed CPR/First Aid which expires on 9/9/24. Licensee did not have immunization records or other required personnel records at the time of the visit.
During inspection, children present were observed to be treated with dignity and respect. Children were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.
Incidental Medical Services (IMS): 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Center and the ADA, available at:
http://www.ada.gov/childqanda.htm
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. LPAs discussed the safe sleep regulations with Licensee 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. LPAs also informed licensee 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.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
12
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST
,
1000 CORPORATE CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BROOME FAMILY CHILD CARE
FACILITY NUMBER:
197408924
VISIT DATE:
11/18/2022
NARRATIVE
1
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5
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7
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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
.
Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. Deficiencies include one type A violation for the hazardous items that were observed in the backyard and seven type B violations for having two baby walkers in the day care room, toys in the play yard, not having a Mandated Reporter Training Certificate, not having immunization records available for review, not having an infant sleep log and not having all required documents for 3 out of 4 children in care at the time of inspection.
A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility.
Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.
A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return.
A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC 9224) shall be in each child’s file, acknowledging receipt.)
Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was given and must remain posted for 30 days.
Appeal rights were discussed and provided to the Licensee.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 9813362
LICENSING EVALUATOR NAME:
Austin Estrada
TELEPHONE:
(323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE:
11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/18/2022
LIC809
(FAS) - (06/04)
Page:
13
of
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