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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493662
Report Date: 08/20/2021
Date Signed: 08/20/2021 10:59:55 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: 3DATE:
08/20/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Fatemen NikTIME COMPLETED:
11:14 AM
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On 08/20/2021 Licensing Program Analyst (LPA) Laticia Thompson conducted an unannounced case management inspection to Nik Family Child Care homes. Upon arrival LPA was greeted by Fatemeh Nik (licensee). LPA toured the facility and observed one infant and one toddler. LPA toured the facility and did not observe any immediate health and safety risk. LPA advised licensee to keep doors to offlimits area closed and inaccessible to children Shortly after tour of facility one small child arrived which was the brother of the infant child. LPA observed facility roster and 3 children records that were being cared for during the inspection. LPA found the files are being maintained properly according to Title 22 regulations.

LPA instructed license to submit an updated application with current landline and cell phone numbers.
Licensee will provide LPA proof of DTAP immunization by 08/24/2021.

LPA provided licensee with a copy of this report and will approvze increase in capacity to a large family childcare home pending manager approval and proof of immunization.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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