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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019364
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:42:41 PM


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:GRAHAM FAMILY CHILD CAREFACILITY NUMBER:
198019364
ADMINISTRATOR:FALLON TIANA GRAHAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 500-5600
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:14CENSUS: 13DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Jiovandra Davidson & Fallon GrahamTIME COMPLETED:
03:00 PM
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On 1/31/2023 at 9:56AM Licensing Program Analyst (LPA) Jennifer Hua conducted an unannounced Required - 1 Year on-site inspection. LPA was greeted by assistant Jiovondra Cullins, per assistant licensee left to pick up/drop off kids. A COVID-19 risk assessment was conducted. Assistant allowed LPA inside the home, Upon entry LPA observed infant was napping in car seat, the car seat was entirely covered and the car seat was on the living room sofa. Assistant stated that baby was just dropped off. LPA also observed assistant was alone with 12 children, 7 of whom are infants. Licensee Fallon Graham arrived to facility at 10:02AM. LPA stated the purpose of the visit and provided LIC 126 Entrance Checklist to facilitate the inspection. LPA was guided to a tour by Licensee. This is a single story home with 3 bedrooms and 2 bathrooms. There are a total of 1 adult and 0 minor residing in the home. At 10:17am, another child was dropped off. There were 13 children in care during the inspection 7 of whom are infants. At 10:21am, licensee's mother Gail Graham (licensee #191511402) arrived. Licensee stated that due to emergency her mom's day care kids were here and her mom is here to take them back to her day care. Licensee stated that parents are aware. At 10:26am, licensee's mom left with 5 children leaving the facility with 8 children in care. At 10:45am licensee left with 1 child to drop child off at home, leaving assistant alone with 7 children. At 11:10am, a child was picked up by parent. Licensee returned to facility at 11:41am alone. The licensee was observed not to be operating within the licensed capacity and is exceeding the required limitations of capacity and ratio. Operating hours are Monday-Friday 5am - 6:30pm.

All child care areas identified on the Facility Sketch were inspected to include the following:
· Childcare areas: Living room, family room, dining area, 1 bedroom, hall bathroom, and fenced backyard is used for outdoor play. Primary care is conducted in the family room.
· Off limit areas: 2 bedrooms, front yard, kitchen, and bathroom in bedroom and garage..

All areas used by children were inspected for safety, comfort, cleanliness, telephone, ventilation and heating (central). The licensees state that there are no poisons in the home. The licensees understand that any poisons must be locked with a key or combination lock. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364
VISIT DATE: 01/31/2023
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The valve on the required 2A 10BC fire extinguisher indicates it was fully charged and serviced on 1/20/22. Smoke and carbon monoxide detector were tested and were operable.

Per licensee, there are no weapon on the premise. There are 3 dogs and isolated in the off limit bedroom away from the children. There are age appropriate toys, equipment were observed for children. Posting requirements were observed to be posted at the time of inspection. There are no bodies of water on the premise

Children Forms/Records to Keep in Your Family Child Care Home were reviewed.
LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov

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 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.

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 Per licensee IMS is not provided at this time.



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.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 10 of 12
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364
VISIT DATE: 01/31/2023
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All adults present have obtained a criminal record clearance. The licensee has proof of current pediatric first aid and CPR (expires: 8/1/24 from the American Red Cross ). Assistant has current American Red Cross Pediatric CPR/First Aid certificate that will expire on 8/1/2024, Licensee has completed required mandated reporter training on 4/19/2022. Roster reviewed but is not current. Per licensee, drills were conducted monthly, Fire drill conducted on 12/16/22 and Earthquake was conducted on on 10/21/22 as observed on the drill log.

No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into this category are not permitted in a family child care facility.

INFANT CARE: The infant will sleep in the day care where they are constantly supervised. Appropriate sleeping arrangements and cribs will be available/observed. (one crib for each infant in care is required). Cribs or play yard will not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and document the time of each 15-minute LIC 9227 Plan shall be completed for each infant up to 12 months of age. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.


Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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/tion-process.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 11 of 12
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364
VISIT DATE: 01/31/2023
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Deficiencies cited on attached 809Ds

Upon receipt of this report documenting a substantiated complaint allegation and a Type A deficiency, the licensee shall do the following:
1. Post the Notice of Site visit and any licensing report documenting a Type “A” deficiency.
2. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.
3. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year).
4. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this visit.

Exit interview was conducted with Fallon Graham, licensee, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role. .
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 12 of 12
Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(g)
Infant Safe Sleep
An infant’s head shall not be covered while sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on observation, the licensee did not comply with the section cited above in which upon, entry, LPA observed infant napping in carseat and carseat was entirely cover with wind protection cover which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Baby was removed from the carseat during visit. License stated baby will be remove from carseat immediately and baby head will not be covered. LIcensee will submit a writtent statement to LPA by 2/2/23.
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which, upon LPA's entry to facility LPA observed an infant napping in carseat and carseat was on the living room sofa, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Infant was removed from the carseat during visit. Per assistant, infant was just dropped off. Per licensee, will ensure infant is taken out carseat immediately upon arrival. Licensee will submit written statement to LPA by 2/2/23
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above in upon LPA;s arrival, LPA observed assitant was alone with 12 children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Per licensee,will ensure to have 2 assistant in place, when licensee has to step away to ensure staffing ratio is met. Per licensee, will submit writen statement by 2/2/23
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,, the licensee did not comply with the section cited above inj upon LPA's arrival, LPA observed assistant was alone with 12 children and 7 of whom are infants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2023
Plan of Correction
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Per licensee, will reduce the number of infants in care, will tell parents to swiitch day care hours to ensure compliance. Per licensee, will submit written statement and to include infant day care schedule/hours.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in, during the inspection,LPA observed 13 children in care, 7 of whom are infant and 6 are preschool-age, none of the children are of school-age which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Per licensee, will reduce 1 child in care to ensure compliance. Licensee will submit written statement to include number of child in care at one time and not to exceed the requirement by 2/2/23
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, the licensee did not comply with the section cited above in upon LPA's arrival, LPA observed assistant was alone with 12 children. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Per licensee, will hire addtional assistant, or will not leave the facility or will take less kids if there are not enough staffing. Licensee will submit written statement explaining how compliance will be met to ensure compliance by 2/2/23
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in assistant certificate expired in August/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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2
3
4
Per licensee, assistant will renew certificate today and will submit copy to LPA by 2/2/23
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in record not available for assistant which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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2
3
4
Per licensee, will correct and submit copy to LPA by the POC due date
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 5 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
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 evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above in licensee does not maintain employee file as required this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
1
2
3
4
Per licensee, will maintain all employee files as required to ensure compliance.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in licensee has added 1 bedroom for day care use and did not notify the Department this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
1
2
3
4
Per licensee, will submit an updated facility sketch to include the bedroom for day care use by POC due date.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 6 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above in record not available for assistant which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
1
2
3
4
Per licensee will submit copy to LPA by POC due date.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed 2 of the children files lack the Consent to Emergency Medical Care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
1
2
3
4
Per licensee, will correct and submit copy to LPA by POC due date.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 7 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in roster is not current/updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
1
2
3
4
Per licensee will update roster and submit copy to LPA by POC due date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review], the licensee did not comply with the section cited above in LPA observed the plan was not completed for 1 infant which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
1
2
3
4
Per licensee, will correct and submit copy to LPA by the POC date.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 8 of 12


Document Has Been Signed on 01/31/2023 02:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: GRAHAM FAMILY CHILD CARE
FACILITY NUMBER: 198019364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in the 15 minute sleep has not been documented for infants as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
1
2
3
4
Per licensee, will document the 15 minute check starting today and submit copy to LPA by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 9 of 12