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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013169
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:16:58 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 CAREFACILITY NUMBER:
198013169
ADMINISTRATOR:DOUGLAS, SHAKENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 375-3636
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: 5DATE:
10/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee - Shakena DouglasTIME COMPLETED:
04:20 PM
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Licensing program analyst (LPA) Randy Derraco conducted an unannounced case management visit to clear deficiencies cited on 08/05/21. LPA met with assistant S2 on 10/19/21 at 2:30 PM. Assistant took LPA on a tour of the facility. LPA observed assistant S3 in main care area with five children in care. LPA observed the main care area to be clean and free of defects. Licensee arrived to facility at 3:40 PM and continued inspection with LPA. Age appropriate toys and materials were observed in the main care area. LPA observed the restroom that children use to be safe and sanitary.

LPA observed children's records to be complete. A barrier was observed to be covering the the wall mounted heater. LPA observed 2A-10BC fire extinguisher with a purchase receipt of 08/26/21. Per licensee, she was unable to produce a copy of mandated reporter certificate due being locked out of her Apple ID profile. LPA advised licensee to package assistant and licensee's file together and send LPA a picture of records via email by 10/22/21.

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

Exit interview conducted and report was reviewed with the licensee Shakena Douglas.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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