197492820-1-12-2022-30-CC-LPHS-CALS54-20220112123343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197492820
Report Date: 01/12/2022
Date Signed: 01/12/2022 01:44:33 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:	DOUGLAS FAMILY CHILD CARE		FACILITY NUMBER:	197492820
ADMINISTRATOR:	DOUGLAS, NICHOLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 835-9406
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY:	14	CENSUS: 3	DATE:	01/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	NICHOLE DOUGLAS		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/12/2022 Licensing Program Analyst (LPA) Loyce Phillips, conducted an unannounced Annual Required Inspection and was met by Licensee, Nichole Douglas. LPA observed 2 children and 1 infant in care. Also present were Licensee assistant. All adults present have a criminal record clearance. The facility operates 24 hours. Licensee is aware that Staff must be awake at all times while children are in care. LPA toured the home inside and outside and a census was taken. The current facility sketch was reviewed and Licensee confirmed that the living room, kitchen, bedroom #1, bathroom #1 and enclosed fenced area in the front yard of the home are accessible to children. Bedroom #2, backyard and garage/storage area is off limits and made inaccessible to children. This is property is a duplex and the front house is off limits. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (323) 835-9406.

SUPERVISOR'S NAME: Peter Flores	TELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce Phillips	TELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 197492820
	VISIT DATE: 01/12/2022

NARRATIVE

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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.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 8/2/2021. Licensee’s pediatric CPR/First Aid expires on 1/13/2023. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

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 Centers 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.

SUPERVISOR'S NAME: Peter Flores	TELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce Phillips	TELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 197492820
	VISIT DATE: 01/12/2022

NARRATIVE

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Licensee is currently caring for infants. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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/inspection-process.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page 809 D) Licensee was provided a copy of their appeal rights.

An exit interview was conducted , a copy of this report was read and provided to the Licensee. This report shall me made available to the public upon request. LIC 9213 Notice of Site Visit was provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Peter Flores	TELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce Phillips	TELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 197492820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(a)

Infant Safe Sleep

(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above. The play yard was located outside in the front yard in disrepair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2022
	Plan of Correction
1 2 3 4	Licensee will provide one crib or play yard for each infant in care by POC.

Type B

Section Cited

CCR

102425(i)

Infant Safe Sleep

If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed infant sleep in a stationary chair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2022
	Plan of Correction
1 2 3 4	Licensee will read PIN 20-24-CCP and PIN 19-02-CCP on Safe Sleep and provide a written statement of her understanding the importance of Safe Sleep.

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: Peter Flores	TELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce Phillips	TELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 197492820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review the licensee did not comply with the section cited above. S2 did not have proof of immunization on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2022
	Plan of Correction
1 2 3 4	LIcensee will submit a copy of S2 immunizations by POC date, by email or mail.

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: Peter Flores	TELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce Phillips	TELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC809 (FAS) - (06/04)

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