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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416986
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:01:14 AM


Document Has Been Signed on 10/05/2022 11:01 AM - 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:CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THEFACILITY NUMBER:
197416986
ADMINISTRATOR:BACH, ROCIOFACILITY TYPE:
830
ADDRESS:15711 S. ATLANTIC AVETELEPHONE:
(310) 637-1593
CITY:E. RANCHO DOMINGUEZSTATE: CAZIP CODE:
90221
CAPACITY:26CENSUS: 5DATE:
10/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Natasha Stallworth, DirectorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Austin Estrada and Alicia Mooberrry conducted an unannounced case management inspection on 10/5/2022. LPAs arrived at the facility at 9:00AM and met with Director Natasha Stallworth, who guided LPAs on a tour of the facility. There was five children and three staff present during the inspection.

The purpose of today's inspection was to go over the water lead test results received on 09/13/2022. Results show that one water source had action level exceedance of lead. The sink located in the Infant Room also referred as the "warming room" had a lead result of 5.7. LPAs observed the sink not to be covered. The door to this room was observed to be closed. The Director stated that the sink is not in use for drinking water or preparing meals. Per Director, filtered drinking water is provided to the infants for drinking and meal preparation. LPAs observed bottles of filtered water in the warming room. Director stated that prepared meals are delivered and infants bring their own formula and milk.

During the inspection, Director covered the sink with a plastic bag and contacted the facility to make corrections to the sink.

A deficiency was cited to ensure that the sink noted will not be used as a drinking source or food preparation source for the infants in care.

The deficiency listed on the following page were observed by the LPAs and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the health & safety of children in care.

Exit interview conducted and report was reviewed with the Director Natasha Stallworth. A notice of site visit was given and must remain posted for 30 days.

Appeal rights discussed and a copy provided.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin EstradaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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 2


Document Has Been Signed on 10/05/2022 11:01 AM - 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: CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THE
FACILITY NUMBER: 197416986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2022
Section Cited

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(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedence

This requirement was not met as evidence by record review.
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Lead test results showed that one water source had an action level exceedence. This is a potential risk to the health and safety of the children 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: Valarie CookTELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin EstradaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2