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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416491
Report Date: 05/03/2021
Date Signed: 05/04/2021 07:58:11 AM

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:SHALOM FAMILY CHILD CAREFACILITY NUMBER:
197416491
ADMINISTRATOR:BOOKOVZA, RACHEL S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 881-1625
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:14CENSUS: 15DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rachel S BookovzaTIME COMPLETED:
02:05 PM
NARRATIVE
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Margarit Sislyan, Licensing Program Analyst (LPA) arrived at the facility and met with Licensee Rachel Bookovza.

LPA toured the facility and observed there were fifteen children were present at the facility along with licensee and 2 assistants.

LPA observed twelve children were sleeping in the converted garage. LPA requested a city permit for occupancy for the converted garage. Licensee will provide the permits to LPA.

LPA observed that there was no space between cats.

LPA observed that the advertising sign in the front of the house did not have a license number on it.

The facility was cited for the violations noticed during the visit.

Licensee was advised that the report will be emailed.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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 3
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: SHALOM FAMILY CHILD CARE
FACILITY NUMBER: 197416491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2021
Section Cited

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Staffing Ratio and Capacity
The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.
This requirement is not met as evidenced by: LPA observed 15 children were present in the facility
Type A
05/03/2021
Section Cited

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Napping Equipment
Napping equipment shall be arranged so that each child has access to a walkway without having to walk on or over the cots or mats of other children.
This requirement is not met as evidenced by:
LPA observed that there was no space between children's napping equipment.

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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: 05/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: SHALOM FAMILY CHILD CARE
FACILITY NUMBER: 197416491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2021
Section Cited

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Advertisements and License Number
Licensees shall reveal each facility license number in all advertisements, publications, or announcements made with the intent to attract clients.
LPA observed the advertising sign in front of the day care did not have a license number
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This requirement is not met as evidenced by:
LPA observed the advertising sign in front of the day care did not have a license number.
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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: 05/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3