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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493662
Report Date: 06/10/2021
Date Signed: 06/11/2021 09:48:25 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:NIK FAMILY CHILD CAREFACILITY NUMBER:
197493662
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
06/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Fatemeh NikTIME COMPLETED:
03:45 PM
NARRATIVE
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On 06/10/2021 Licensing Program Analyst (LPA) conducted an unannounced visit for an increase in capacity. and observed the following deficiencies: .
  • LPA observed a toddler holding a can of lysol which is hazardous and poisonous to children in care
  • Kitchen contained sharp knives and hazardous/poisonous material accessible to children in care.
  • Bathroom cabinets and counters contained hazardous/poisonous material accessible to children in care
  • Scissor in the bathroom drawer were accessible to children in care
  • LPA reviewed children’s files and found that licensee has not maintained files in compliance with Title 22


Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be obtained as proof of parent’s receipts. LPA instructed licensee to post LIC 9213- Notice of Site Visit. Notice of Site Visit must be posted for 30 days. Failure to post required visit reports for 30 consecutive days will result in immediate civil penalty assessment of $100.

An exit interview was conducted, appeal rights and progressive civil penalties were explained, and a copy of this report was given to licensee by email. Licensee is instructed to reply to email acknowledging a copy was received. Licensee is also instructed to mail the report back to department with a signature within 3 business days.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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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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: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197493662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2021
Section Cited

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102417 Operation of a Family Child Care Home Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children (a)Storage areas for poisons...shall be locked This requirment was not met as evidence by
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Based on observation cleaning compounds were not stored and locked properlly, a sharp knives were left on the counter, in sink and scissors were acceissble to children which poses an immediate health and safety risk to children under care.
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Type B
06/10/2021
Section Cited

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1012417Operation of a Family Child Care Home (g)(7) An emergency information card shall be maintained for each child...include the child's full name, telephone number and location of a parent or other...to be contacted in an emergency... The requirement is not met as evidenced by
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Based on record review children files were found to be incomplete and missing information,which poses an potential Health Safety, risk to 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: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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