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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492777
Report Date: 11/30/2021
Date Signed: 11/30/2021 04:24:27 PM

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:ALLEN FAMILY CHILD CAREFACILITY NUMBER:
197492777
ADMINISTRATOR:ALLEN, EBONIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 812-3683
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Edoni Allen TIME COMPLETED:
04:30 PM
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On 11/30/21 Licensing Program Analyst (LPA) Dalicia Adkins conducted a case management visit and met with licensee Eboni Allen and was provided a tour of the home inside and outside. There were 5 children present and no other adults. This is a single story 3 bedroom 3 bathroom home with detached garage.

During case management visit LPA observed the bedroom knob missing , and no lock. This room is located next to the primary room that is utilized to care for children. LPA confirmed with licensee that off limits rooms shall be inaccessible to children in care. LPA inspected the room and did not observe any current conditions that may be of harm to children in care. LPA provided guidance and technical support. Licensee was given a Technical Violation (TV) refer to TV LIC 9102TA. Licensee stated that she will put lock and or safety door knob on door to make room inaccessible to children in care. Licensee agreed to put lock and or safety door knob no later than December 8th, 2021.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources. LPA referred licensee to Resource and Referral for additional resources.

Per Title 22 of the California Code of Regulations, no deficiencies are cited.
Exit interview conducted , copy of this report provided and reviewed with licensee.

LIC 9213 Notice of Site Visit provided and required to be posted for 30 days.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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