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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:15:38 PM


Document Has Been Signed on 12/06/2023 04:15 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
MONTEREY PARK SW RO, 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: 5DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee - Shameka NicholasTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Randy Derraco conducted an unannounced case management visit to the above mentioned facility on 12/06/23. LPA began inspection at 3:00 PM and was met by licensee, Shameka Nicholas, who guided analyst on a tour of the facility. LPA observed 2 adults and 5 children in care. The purpose of this visit is to issue citations to violations observed during case management visit. During record review, licensee provided a copy of Mandated Reporter Training certificate dated 06/30/21. LPA advised licensee that a citation under Health and Safety Code (HSC) section 1596.8662(b)(1) will be issued. Licensee was also advised to include a personnel record in her employee files.

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 Shameka Nicholas.

SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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 2


Document Has Been Signed on 12/06/2023 04:15 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
MONTEREY PARK SW RO, 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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
HSC
1596.8662(b)(1)

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1596.8662 Availability of information...(b)(1)On or before March 30, 2018, a person who... is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...This requirement is not met as evidenced by:
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Licenee states she will email LPA a copy of completion certificate before POC date
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Based on observation, interview and record review, the licensee did not complete Mandated Reporter AB1207 compliant trainig after two years which poses a potential risk to the health and safety of the persons in care.
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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: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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