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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012957
Report Date: 10/18/2022
Date Signed: 10/18/2022 04:05:07 PM


Document Has Been Signed on 10/18/2022 04:05 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:BLAYLOCK FAMILY CHILD CAREFACILITY NUMBER:
198012957
ADMINISTRATOR:BLAYLOCK, DONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 583-8551
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:14CENSUS: 10DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donna Blaylock, LicenseeTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 10/18/22 at 1:00 PM. LPA met with Donna Blaylock, Licensee who guided analysts on a tour of the facility. There were 10 children and four adults present when LPA arrived.

This is a one-story home which consists of three bedrooms, two bathrooms, kitchen, living room, front yard and backyard (fenced). LPA observed an ADU behind the home with a separate address 822 E. 73rd. Main care is provided in the living room and three bedrooms. Per Licensee, there are no areas off limits. Hours of operation are Monday-Sunday, 23 hours.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form.

Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 10/4/2022.

Dual Smoke and carbon monoxide detector is located in the living room. Detector was tested and is operable. Fire extinguisher indicated fully charged and was last serviced 3/2022.

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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957
VISIT DATE: 10/18/2022
NARRATIVE
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The home maintains telephone service via cell phone and landline. The children have access bedroom #1 near the entrance of the home, this room has a television, furniture and games for older children. The living room has toys and other age appropriate material available for all children. Bedroom#2 is behind the kitchen is used for nap and activities for young children. Bedroom #3 is used for infant nap and infant activities. Detergents and cleaning compounds are stored on a high shelf in the bathroom closest to the entrance, inaccessible to children. Isolation area for sick children waiting to be picked up is in the bedroom closest to the entrance. Home has central air and heat. Per Licensee there are no firearms or weapons stored in the home.

The bathrooms that children use are at the front of the home and at the back of the home between the two main care bedrooms. Bathrooms were observed to be clean and free of hazards. Licensee was reminded to measure inaccessibility of cleaning product by the height of her tallest school age child. If the child can reach it, it is not inaccessible.

Infant Care: Licensee currently has one infant in care. LPA observed two cribs in the infant bedroom and two more cribs disassembled. Napping equipment does not block entrances or exits. Infant mattress was observed to be firm with tightly fitted mattress pad. Fitted crib sheets were discussed with licensee. LPA observed bumpers and blankets in both cribs. There was no infant in the crib at the time inspection. Licensee removed all items from the crib infant will be sleeping in during inspection. There are currently no infants with pacifiers. Per licensee wet or soiled sheets are changed as needed. Bedding is washed weekly. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following a sleep supervision plan for infants: a staff member stays in the room with the infant while they sleep.

Overnight Care: Licensee currently does not have overnight children in care. Licensee is aware that they must remain wake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

Currently, children are using the back yard for outdoor play. 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. LPA did not observe any hazards outdoors. LPA observed that there are no bodies of water at the facility.


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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957
VISIT DATE: 10/18/2022
NARRATIVE
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Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment and LIC 995A Notification of Parents’ Rights. All documents were observed. LPA observed that two children are missing immunization records and LIC 627. Infant in care is missing LIC9227 and 15 minute Sleep Plan.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. LPA observed that five out of five staff are missing immunization's and four out of five staff have expired mandated reporter training certificates.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a plan for providing 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 Center 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.

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 -------------------PAGE 3

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957
VISIT DATE: 10/18/2022
NARRATIVE
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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 also informed licensee [facility representative] 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.

Exit interview conducted and report was reviewed with the Facility Licensee, Donna Blaylock.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/18/2022 04:05 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 3 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee will have staff update training and email current certificates to LPA by POC date 11/18/22
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 4 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee will get copies of all staff immunization records and email to LPA by POC date 11/18/22

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 10/18/2022 04:05 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 2 out of 3 children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee will contact parents and ask them to bring in records and email them to LPA by POC date 11/18/22
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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 for one infant in are which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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licensee will begin documenting nap times and email LPA completed log by POC date 11/18/22

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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