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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494026
Report Date: 06/03/2021
Date Signed: 06/04/2021 03:29:51 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:SHIRAYURI YOUCHIENFACILITY NUMBER:
197494026
ADMINISTRATOR:AOYAMA,YOSHIOFACILITY TYPE:
830
ADDRESS:20706 NORMANDIE AVENUETELEPHONE:
(310) 530-5830
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:10CENSUS: 8DATE:
06/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tomi AoyamaTIME COMPLETED:
12:35 PM
NARRATIVE
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On 6/3/2021, Licensing Program Analysts (LPAs) Lillian Casillas and Jillinda Chandler conducted an unannounced Case Management inspection. LPAs met with Teacher, Tomi Aoyama, who led LPAs through the indoor and outdoor of the facility.

At 11:30 AM, LPAs entered the facility. At 11:35 AM, LPAs observed Child 1 (C1) asleep in a crib with a blanket covering the infant's head. LPAs also observed a long pillow to the left of the infant, placed against the railing of the crib and a circular fabric item hanging from railing above C1's head. LPA Chandler advised Mrs. Aoyama, Staff 1 (S1), and Staff 2 (S2) that the heads of infants cannot be covered while sleeping. Mrs. Aoyama stated, "That's how she sleeps." LPA Chandler removed the blanket from the infant.

Based on observations and interviews, LPAs issued a LIC 9102 Advisory Notes - Technical Violation to offer consultation on Community Care Licensing's COVID-19 Guidelines. LPAs also cited a Type A deficiency pursuant California Code of Regulations Title 22 Safe Sleep Regulations (see LIC9099-D for details). Upon receipt of this report, the Director must post the report along with the Notice of Site Visit for 30 days for parents to view. A copy of this report must be provided to parents/guardians of children in care at the facility and parents/guardians of children newly enrolled at the facility of this Type A citation for the next 12 months (1 year). The report shall be provided, no later than the next business day or the next day that the child is in care. The LIC 9224 Acknowledgement of Receipt of Licensing Reports shall be signed and kept in each of the children’s records. If the Licensee fails to comply an $100.00 civil penalty shall be assessed for each family enrolled and in attendance.

An exit interview was conducted, and, due to COVID-19, a copy of this report, LIC 9213 Notice of Site Visit , and Appeal Rights were emailed to Tomi Aoyama, who agreed to reply to the email in lieu of a signature.

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SHIRAYURI YOUCHIEN
FACILITY NUMBER: 197494026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2021
Section Cited

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101430 Infant Care Activities (a) Notwithstanding Section 101230, the following shall apply: (3) All infants shall be given the opportunity to sleep without... (D) An infant's head shall not be covered while sleeping.
This requirement was not met as evidenced by:
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Based on observation and interviews, the facility failed to comply with Safe Sleep Regulations as C1 was asleep with a blanket covering the infant's head, which poses an immediate health, safety, or personal rights risk to children in care.
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Type A
06/03/2021
Section Cited

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101439.1 Infant Care Center Sleeping Equipment (a) In addition to Section 101239.1, the following shall apply. (f) Cribs shall be free from all loose articles and objects, including blankets and pillows. (3) There shall be no objects hanging above or attached to the side of the crib.
This requirement was not met as evidenced by:
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Based on observation, the facility failed to comply with Safe Sleep Regulations as C1 was asleep with a pillow placed alongside the left side of the crib and a circular fabric item was hanging from crib above C1's head, which poses an immediate health, safety, or personal rights 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: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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