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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 10/05/2021
Date Signed: 10/06/2021 11:07:24 AM

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:NICHOLAS FAMILY CHILD CAREFACILITY NUMBER:
198017228
ADMINISTRATOR:NICHOLAS, SHAMEKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 788-0855
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: 3DATE:
10/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee - Shameka NicholasTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) R. Derraco conducted an unannounced annual inspection to the above facility on 10/05/21. LPA arrived at the facility at 10:00 AM and met with assistant Maria Ochoa, who guided analyst on a tour of the facility. An entrance checklist was provided to the assistant upon entering the home. Also present during this inspection was S3. Per Licensee, there are 16 children that are currently enrolled. There were 2 children present upon arrival. LPA observed 1 child being dropped off for care at 10:18 AM. At 10:30 AM, LPA met with licensee who took over the guided tour of the facility.

This is a one story home which consists of 3 bedrooms, 2 bathrooms, kitchen area, dining area, living room, a attached garage, front yard and backyard (fenced). The off limit areas include 3 bedrooms, 1 bathroom, kitchen area and attached garage. LPA observed the living room and dining area to be used as the main care area. LPA observed age appropriate toys and materials. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted on the wall next to the entrance of the home. LPA observed the off limits hallway to be accessible to children. LPA also observed the cabinet below the sink to be unlocked and contain cleaning detergents and disinfectants. Licensee states children pass through the kitchen to reach the restroom. Licensee states she will add baby gates separating the main care area from the off limits hallway and the kitchen area. LPA observed that there is a fireplace in the living room that is screened and locked. A floor heater was observed to be accessible to children in care. Licensee states she had gas company shut off gas to heater a couple of years ago however she was unable to provide a service tag. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to have perimeter fencing. LPAs observed that the outdoor yard has toys and other materials for children to play with. A storage shed was observed to have a combination lock making contents inaccessible. A barbecue grill and fire pit were observed to be covered in the back yard. LPA observed dog feces in the grassy areas of the backyard. Licensee explains that her son cleans the backyard everyday at 1 PM, after he is done with his online courses. Licensee then provided cleaning logs for her son showing previous dates,
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 10/05/2021
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including yesterday's date signed with a time stamp of 1 PM. Licensee further explains that children do not go outside until after 1 PM after she confirms that backyard has been cleaned. There was one dog observed on the premises. No bodies of water were observed in the back yard play area. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs.

The licensee states that she provides food for children in care. Licensee states that there are no firearms stored in the home. Individuals who reside in the home were noted and discussed. Per Licensee, she currently has 3 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 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.

Per licensee, isolation area for children showing signs of illness will be on the front porch with supervision while they wait to be picked up by their parents or authorized representative. There is telephone service via a landline.

The licensee states that ant spray and weed killer is stored in the outdoor storage shed. Licensee understands that storage areas for poisons must be locked, not just inaccessible. The restroom that children use was observed to be safe and sanitary.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 06/30/21, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable.

LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep web page 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
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 10/05/2021
NARRATIVE
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recalls on their purchased equipment.
LPA observed one Guava Family playpen in the day care area. The playpen was 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 pen. LPAs advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants aged 0-12 months 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 and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 01/2023. 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 and were observed to be complete. A current children’s roster was available for review.

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.

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

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 10/05/2021
NARRATIVE
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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.

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.


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

Exit interview conducted and report was reviewed with the licensee Shameka Nicholas.

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

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC809 (FAS) - (06/04)
Page: 5 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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021

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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee will contact gas company and send LPA copy of service tag showing heater is inoperable.
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee will send LPA pictures of baby gates making kitchen inaccessible.
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: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021
LIC809 (FAS) - (06/04)
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