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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011471
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:57:37 PM


Document Has Been Signed on 06/22/2023 03:57 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:CAMPBELL FAMILY CHILD CAREFACILITY NUMBER:
198011471
ADMINISTRATOR:CAMPBELL. DONNITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 733-2737
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:14CENSUS: 5DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Donnita CampbellTIME COMPLETED:
04:15 PM
NARRATIVE
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At 2:00pm Licensing Program Analyst (LPAs) Mary Silva and Judy Mora conducted an unannounced required 1-year inspection to the above facility. LPA(s) met with Licensee, Donnita Campbell, to whom the reason for the visit was explained. Per Licensee, there are 14 children currently enrolled. There were 5 children present upon arrival. During this visit, Licensee’s assistant was also present. The licensee was observed to be operating within the license capacity limitations.

The licensee states that 3 adults and no children currently live in the home. All adults living in the home have obtained a criminal record clearance.

This is a one-story home which consists of 4 bedrooms, 2 bathrooms, living room, dining room, playroom, kitchen, laundry room, front yard, and backyard which is fenced. LPA(s) observed construction is currently taking place at the facility.

Per licensee, areas off limits to children and parents include 4 bedrooms, 1 bathroom, kitchen, laundry room and front yard. The children have access to playroom, one bathroom, and backyard which is fenced.

Licensee guided analysts on a tour of the facility at 2:22pm. During this visit, all areas identified on the facility sketch that are currently accessible for children to use were toured and inspected.

Facility License, Emergency Disaster Plan, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the entry way of the playroom. A current children’s roster was available for review. Page 1 of 4
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Mary SilvaTELEPHONE: (323) 558-2711
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 198011471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher was observed to be fully charge but did not have a service tag which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee stated the fire extinguisher will be services by POC date. Licensee will submit verification of service tag by POC date.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 child files was not availabe for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee stated file for child #1 will be availabe for review by POC due date.
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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Mary SilvaTELEPHONE: (323) 558-2711
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 198011471
VISIT DATE: 06/22/2023
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There is telephone service via a cellphone that stays at the facility during operation hours. Hours of operation are Monday – Friday, 6:40am-6:30pm. There is ventilation and central heating in the home.

Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee there are no poisons in the home. LPA advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms or weapons stored in the home.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and no service tag was observed. Smoke and carbon monoxide detectors were tested and are operable.

All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 06/09/2023.

The home is observed to be clean and orderly. There are first aid supplies available. There are age-appropriate toys available for children. Appropriate sleeping arrangements in form of cribs and cots were observed.

Licensee states that she is not currently caring for any infants.

Per licensee, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. No bodies of water were observed on this day.

At 2:25 pm Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights. One child present did not have a file.


At 2:40 pm Licensee and staff records were reviewed, and LPAs observed that Licensee has a Pediatric First Aid and CPR card with the expiration date of 04/2019.
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SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Mary SilvaTELEPHONE: (323) 558-2711
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 198011471
VISIT DATE: 06/22/2023
NARRATIVE
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LPA observed that the Licensee and assistant have completed the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file with expiration on 06/21/2023 for licensee and assistant. www.mandatedreporterca.com

There are 2 dogs on the premises. Per licensee, the dogs are kept outside in off limits areas during daycare hours.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, trampolines, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family child care facility.

LPA also informed licensee Donnita Campbell of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. Per Licensee, there are currently no children on medications. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process. Page 3 of 4
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Mary SilvaTELEPHONE: (323) 558-2711
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 198011471
VISIT DATE: 06/22/2023
NARRATIVE
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Licensee, was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA(s) also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.


A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Mary SilvaTELEPHONE: (323) 558-2711
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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