198013169-8-5-2021-54-CC-RDEO-C5LRNS-20210805131050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198013169
Report Date: 08/05/2021
Date Signed: 08/05/2021 01:11:03 PM

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:	DOUGLAS FAMILY CHILD CARE		FACILITY NUMBER:	198013169
ADMINISTRATOR:	DOUGLAS, SHAKENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 375-3636
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY:	14	CENSUS: 9	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee - Shakena Douglas		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) R. Derraco conducted an unannounced annual inspection to the above facility on 08/05/21 LPA arrived at the facility at 9:00 AM and met with S2, who guided analyst on a tour of the facility. Licensee, Shakena Douglas, arrived to the home at 9:15 AM. Per Licensee, there are 19 children that are currently enrolled. There were 3 children present upon arrival. At 9:08, LPA observed 2 children being dropped off. At 9:45 AM, LPA observed 2 additional children dropped off. LPA observed S3 arriving 10:38 AM. LPA observed 2 additional children being dropped off at 11:20 AM. LPA observed a total of 9 children in care, 1 child is 13 years old. This is a 1-story home which consists of 3 bedrooms, 2 bathrooms, kitchen/dining room, living room, front yard and backyard (fenced). The off limit areas include the kitchen/dining room, 2 bedrooms, and a bathroom. A sliding wooden door is used to separate the off limit areas from the day care area in the home. The back yard was observed to have a wooden fence and gate with lock making the area inaccessible to children. LPA observed an off limits back yard area to have an additional off limits living area. Per licensee, the off limits living area is called a "rumpos room". Per licensee, she uses this room as a personal private space. The living room, master bedroom and front yard is set up for day care use. The master bedroom has been converted into the main care area. LPA observed the main care area to have a half bathroom, a wall mounted television, storage cubbies for children in care, a locked storage cabinet with children activities and supplies, age appropriate toys, materials, tables and chairs. LPA observed 3 Cosco feeding high chairs model HC225FGT in the main care area. The bathroom that children use was observed to be safe and sanitary. The living room has been converted to care for infants that are enrolled to the day care. LPA observed 5 "Dream on Me" pack an play pens model number 438. A wall mounted television was observed in the infant care room. LPA observed a children's cubby storage cabinet and a Holmes Air purifier against the wall leading to the main care area. A wall mounted air conditioning / heating unit was observed to be built Page 1 of 3

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy Derraco	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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 5

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
	VISIT DATE: 08/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

into the wall below the window. LPA observed the unit was not screened. A citation will be issued under CCR 102417(g)(1). The licensee states that she provides food for children in care. Per licensee, isolation area for children showing signs of illness will be kitchen/dining area. Currently, children are using the front yard for outdoor play time. The outdoor play area was observed to have perimeter fencing. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children in care. No bodies of water were observed in the front or the back yard area. LPA observed one small dog in the home. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs.

Individuals who reside in the home were noted and discussed. Per Licensee, they currently have two assistants. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed childcare home. Licensee states that there are no firearms stored in the home.
There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. Per Licensee, the home was purchased without a furnace. Heat is provided from the wall unit in the infant care room. Day care area was observed with safe toys, play equipment and materials.

Detergents, cleaning compounds, and other items which could pose a danger to children were observed to be beneath the sink in the off limits kitchen. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked. No sharp objects were observed to be accessible in the kitchen area.

The valve on the required 2A10BC fire extinguisher indicates fully charged but did not have a service tag. Licensee states she had purchased the fire extinguisher in 01/2021 but failed to provide a receipt. A citation will be issued under CCR 102417 (g)(1). Smoke and carbon monoxide detectors were tested and are operable.

Safe sleep guidelines were discussed with licensee. Five play pens were observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the play pens. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants Page 2 of 3

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy Derraco	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
	VISIT DATE: 08/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age.

The licensee was unable to provide personnel records for her staff. A citation will be issued under CCR 102416.1 (d) for personnel records. LPA observed that children records were not available reveiw. A citation will be issued under CCR 102421 Child Records. A current children’s roster was available for review. An LIC 311D was given to the licensee.
Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

Incidental Medical Services (IMS):
IMS was discussed with licensee. Per licensee, there are no children enrolled that require IMS at this time. 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov. LPA also discussed the Provider Information Notices (PINS) on Recently Approved Safe Sleep Regulations in Effect: PIN 20-24-CCP, Safe Sleep Awareness Campaign: PIN 19-02-CCP and Guardian User Account Access - PIN 20-20-CCLD. Copies of the PINS were provided to the licensee. An example for the Infant Sleep Chart was provided to the licensee
The following deficiencies listed on the attached LIC 809 (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.

Exit interview was conducted with Shakena Douglas, Licensee, including, but not limited to Appeal Procedures, Site Visit and Initial Appeal Rights. Page 3 of 3

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy Derraco	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/05/2021 Section Cited	1 2 3 4 5 6 7	102417 Operation of Family Child Care Home (g) The home shall be free from...conditions which might endanger a child...(1)...open-face heaters shall be screened ... The home shall contain a fire extinguisher... established by the State Fire Marshal. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation, interview and record review, the licensee did not provide a service tag for the fire extinguisher and the air conditioning / heater wall unit is not fenced. This poses a potential health, safety and/or personal rights risk to persons in care	8 9 10 11 12 13 14
Type B 08/05/2021 Section Cited	1 2 3 4 5 6 7	102417 Child Records. This requirement is not met as evidence by: Based on observation, interview and record revew, the licensee did not provide children records for review. This poses a potential health, safety and/or personal rights risk to persons in care
	1 2 3 4 5 6 7

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 Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy Derraco	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/05/2021 Section Cited	1 2 3 4 5 6 7	102416 Personnel Records (d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation, interview and record review, the licensee did not provide personnel records for review. This poses a potential health, safety and/or personal rights risk to persons in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy Derraco	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

Page: 5 of 5