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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013169
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:24:38 PM


Document Has Been Signed on 01/12/2023 03:24 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:DOUGLAS FAMILY CHILD CAREFACILITY NUMBER:
198013169
ADMINISTRATOR:DOUGLAS, SHAKENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 375-3636
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: 13DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee - Shakena DouglasTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) R. Derraco conducted an unannounced required one year inspection to the above facility on 01/12/23. LPA arrived at the facility at 11:50 AM and met with Licensee, Shakena Douglas, who guided analyst on a tour of the facility. Also present during this inspection were 2 assistants. Per Licensee, there are 26 children that are currently enrolled. There were 10 children present upon arrival. LPA observed licensee leaving at 12:55 PM and returning at 1:17PM with 2 additional children. Licensee left again at 1:20PM to pick up another child from school.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen/dining room, 2 living rooms, a detached garage that has been converted into a living space, front yard fenced and backyard. The off limit areas include 3 bedrooms, 1 bathroom, kitchen/dining area, detached garage, and backyard.

The main care area is located in living room 1. LPA observed a wall mounted television, wooden storage lockers for personal belongings, 5 highchair feeding tables, child sized tables, child sized chairs, age appropriate toys, art materials and napping cots. Living room 2 was observed with 5 "Dream On Me" playpens, children's reading material, a storage cubby for personal belongings, a wall mounted television and a child sized table with chairs. A sliding wooden door was observed to separate living room 2 and the off limits kitchen area. The bathroom designated for children in care was observed to have a operational faucet, sink and toilet. The outdoor play area is located in the front yard. LPA observed perimeter fencing, adequate shade, outdoor play equipment, and a climbing structure. Artificial grass was observed on the ground beneath the climbing structure. The licensee states that she provides food for children in care. Per licensee, isolation area for children showing signs of illness will be located in living room 2 where they will await parent pick up. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs. LPA did not observe any objects that can pose a danger to children in care. A pet dog was observed to be kept in the off-limits kitchen
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 6


Document Has Been Signed on 01/12/2023 03:24 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: DOUGLAS FAMILY CHILD CARE
FACILITY NUMBER: 198013169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

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, interview and record review, the licensee did not service or replace her fire extinguisher 12 monnths after it was purchased which poses a potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
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Licensee states she will service or purchase a new fire extinguisher and send LPA a copy of service tag or receipt.
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 observation, interview and record review, the licensee did not document and maintain each child's immunization record which poses and potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
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Licensee states she will update all enrolled children's files with immunization records. Licensee states she will send LPA a declaration stating she will document and maintain immunzation records for each enrolled child.
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: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 2 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: DOUGLAS FAMILY CHILD CARE
FACILITY NUMBER: 198013169
VISIT DATE: 01/12/2023
NARRATIVE
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area. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted in living room 2. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

Individuals who reside in the home were noted and discussed. 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. Licensee states that there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety,
comfort, and cleanliness. There is telephone service via a land line. Per Licensee, the home is equipped with a heating and air conditioning unit located in living room 2. 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 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 not just inaccessible. The valve on the required 2A 10BC fire extinguisher indicates fully charged however licensee was unable to provide a purchase receipt. LPA advised licensee that a citation under California Code of Regulation (CCR) section 102417 (g)(1) will be issued. Smoke and carbon monoxide detectors were tested and are operable.

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 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.

The licensee and other personnel have completed training on preventive health practices including Pediatric
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOUGLAS FAMILY CHILD CARE
FACILITY NUMBER: 198013169
VISIT DATE: 01/12/2023
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First Aid and CPR. Assistant's CPR expires in 08/2023. LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. File review was observed to have proper mandated immunization records. Children’s records were reviewed, including emergency information. LPA observed that immunization records were missing for 3 children. LPA advised licensee that a citation under CCR section 102418(g) will be issued. A current children’s roster was available for review. LPA advised licensee to fill in missing information (start / end date, parent contact information).

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.cdss.ca.gov.

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.

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.

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

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

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6