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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412349
Report Date: 03/11/2024
Date Signed: 03/11/2024 08:13:56 PM


Document Has Been Signed on 03/11/2024 08:13 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:CAMPBELL FAMILY CHILD CAREFACILITY NUMBER:
197412349
ADMINISTRATOR:CAMPBELL, RAYE M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 756-7027
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:14CENSUS: 1DATE:
03/11/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Raye M. Campbell- LicenseeTIME COMPLETED:
01:10 PM
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On 3/11/2024 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual 3 Year Required Inspection at above mentioned facility.
Upon arrival, LPA was by greeted by Raye Campbell. LPA observed one child in care.

The hours of operation are Monday through Friday 7:00 a.m. to 6:00 p.m. Currently facility is available to take children ages birth to 5 years old. Licensee is available to take older children but does not have anyone enroll. Facility is licensed for a Large Family Child Care license with a max capacity of 14 children.

The home is a one story, three bedroom, 2 1/2 bathroom with an open living room/dining room area, den, kitchen and attached garage. Living in the home is Licensee and two additional adults. Per Licensee, no child care is conducted in the attached garage. Licensee confirmed the following OFF LIMITS AREAS: Master bedroom and bathroom, bedroom 2 and bedroom 3, full bathroom and Kitchen area. Kitchen was observed with a door and safety gate making the area inaccessible. LPA reminded licensee that any area designated as OFF LIMITS need to be made inaccessible to the children in care- door closed and locked during the hours of operations and/or while children are present.

Living room and dining room area are used as a walkway to access the day care space.
Licensee confirmed the day care space is located in the den area, located in the rear of the home.

Licensee confirmed that the ½ bathroom located next to the kitchen has been designated as day care use. Bathroom that children use was observed and inspected. LPA reminded Licensee to ensure all toiletries and cleaning supplies need to be made inaccessible to the children in care; LPA observed items on the top shelve above the toilet.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 03/11/2024
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The licensee was informed that any changes to ages, hours and days of operation shall be submitted to the department via signed LIC 279, for approval prior to initiation of changes.

LPA observed the area designated for day care use and observed age-appropriate toys. Licensee confirmed children nap in the den area. LPA observed a pack and play in the space. Living room was observed to have a parent board and LPA provided Licensee with the current copies of all necessary postings.

The outdoor space was inspected. Licensee confirmed that at the moment she does not have any children that use the outdoor space. LPA informed licensee to ensure that outdoor space and equipment is inspected regularly to ensure equipment is free of hazards. Home was observed with age appropriate outdoor equipment including a wooden play structure. LPA discussed the importance of making sure wooden apparatus is inspected to ensure it continues to stay safe and without.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. LPA observed a barricaded fire place in the living room and den area.

Detergents and cleaning compounds are under sink cabinet in the kitchen area and top shelf in the ½ bathroom. Kitchen is made in accessible to the children in care- LPA observed a closed door and safety gate on both entry points of the kitchen.

Homes is open to take in children that need medication. Licensee confirmed that she currently does not have any children that need medication. Prescription medications shall be administered in accordance with the label directions as prescribed by the child’s physician. Medication should be in its original content with all necessary LIC forms completed.

LPA observed licensee test the smoke detector in the home. A working fire extinguisher was observed in the home near the kitchen. Licensee confirmed that fire drills and earthquake drills are completed. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 03/11/2024
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Licensee provide meals and snacks. LPA discussed the importance of maintaining a system where allergies and food restrictions are noted. LPA encourage licensee to contact their local resource and referral agency, Crystal Stairs, to inquiry about the different resources and professional development opportunities available.

Adequate heating and ventilation for safety and comfort were observed in the space. Safe toys and play equipment were observed. The home has a working telephone service and
LPA confirmed the phone number and email address.

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.

Capacity as specified on the license is being maintained during today’s inspection; 1 child was present during today’s inspection.

Safe Sleep regulations were discussed due to program being available for infant care. 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 physically checks 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. Infants up to 12 months of age are placed on their backs for sleeping. LPA discussed the importance of maintaining a current sleep log for all children under the age of 24 months. Individual Infant Sleeping Plan was provided and discussed with licensee.

Licensee’s Mandated Reporter Training was not available for review- Type B citation was issued. Licensee agrees to complete necessary training and submit copy of completion to LPA via email and/or United States Postal Service. Licensee’s Pediatric CPR and Pediatric First was taken on 5/12/2022. LPA reminded licensee the importance of making sure all vendors providing Pediatric CPR and Pediatric First Aid need to be EMSA approved. Licensee’s proof of immunization as not available for review- Type B citation was issued.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 18
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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 03/11/2024
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Children’s file were not available for review- LPA cited a Type B citation. The licensee shall keep the signed and dated notice form for at least three years following
termination of service to the child. LPAs discussed all necessary forms needed in each staff file and children’s file.

LPA provided licensees with a current copy of the LIC 311D and LIC 126 to use as a reference when auditing files; hard copies were provided during today’s inspection.


A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee Raye Campbell.

Copy of this report with appeal rights were provided to Licensee Raye Campbell.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.



LPA 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. LPA 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. PIN 22-05-CCP Page Five
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 17 of 18
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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 03/11/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 18 of 18
Document Has Been Signed on 03/11/2024 08:13 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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

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 not having a completed mandated reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to complete training and submit verification via email and/or USPS to LPA.
Www.mandatedreporterca.com
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
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Based on record review, the licensee did not comply with the section cited above in not having Licensee's copies of immunization record available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to provide copies of immunization records:Pertusis, measles and Influenza to LPA via email and/or USPS
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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 18


Document Has Been Signed on 03/11/2024 08:13 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: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out 1 files not available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to have a completed child's file to with all the necessary documents- copies will be submitted via email and/or USPS
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 18