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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493786
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:47:53 PM


Document Has Been Signed on 09/14/2022 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:ALLEN FAMILY CHILD CAREFACILITY NUMBER:
197493786
ADMINISTRATOR:YOLANDA ALLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 571-2262
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:14CENSUS: 1DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:16 PM
MET WITH:Yolanda Allen, Licensee TIME COMPLETED:
04:55 PM
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On 09/14/2022, 4:16pm, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management - other for the purpose of the health and safety of the family child care.
LPA Miranda observed 1 child (who 1 was infant) in care with licensee with and two assistants. Per licensee she has 6 children enrolled on her family child care.

During this inspection, Licensee disclosed that on 09/3/2022 she had 3 positive cases, that was not report to Department of Social Services.

Licensee will submit the LIC624 unusual incident report due the positive covid-19 cases, no later than 09/15/2022 via email to LPA Miranda. Advisory notes, was provide with guidance regarding report requirement to Licensee.

Also, LPA provided copy of LIC624 form, LIC311A Forms/Records to Keep in your Family Child care and Brochure of SIDS, form LIC9227 Individual Infant Sleep and Safe Sleep - Frequently Asked Questions.

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Yolanda Allen, Licensee.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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