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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494704
Report Date: 03/22/2021
Date Signed: 03/22/2021 10:53:26 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:HAYES FAMILY CHILD CAREFACILITY NUMBER:
197494704
ADMINISTRATOR:HAYES, ERNESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 780-0885
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:14CENSUS: 0DATE:
03/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Ernestine HayesTIME COMPLETED:
11:00 AM
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On 03/22/2021 at 10:27 AM Licensing Program Analysts (LPA) Stella Gutierrez conducted an announced follow-up pre-license tele inspection via FaceTime with Ernestine Hayes. The purpose of today’s inspection is the change in physical plant operation where main care will be provided. Applicant was provided with a change of location inspection on 03/08/2021 and it was determined that main care area/ recreation room that is detached from the home is not permitted at this time. Main care area will be provided in home until the detached room is permitted and another inspection is conducted with Applicant with approval from CCLD.

During today’s inspection LPA, Gutierrez observed all recreational items that were provided in detached/non-permitted room to be relocated inside home/Living room area. Applicant was advised to sign a declaration stating that detached recreation room will be off limits until approved by CCLD upon completion of received permit and a follow-up inspection with assigned Analyst.

Pending items needed post Pre license follow up visit:

1. Lease agreement


2. Declaration LIC 855
3. New Facility sketch showing that recreational room is off limits.
4. IMS Plan of operation
5. Pictures of the new main care area provided in the living room of home and detached room off limits.

An exit interview was conducted, and a copy of this report was provided to the Applicant, Ernestine Hayes. Final decision of License issuance will be determined by the department unit Licensing Program Manager.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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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