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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019922
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:02:42 PM


Document Has Been Signed on 08/02/2024 03:02 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:HENDERSON FAMILY CHILD CAREFACILITY NUMBER:
198019922
ADMINISTRATOR:ROBIN HENDERSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 756-3137
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:14CENSUS: 3DATE:
08/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Robin Henderson, LicenseeTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Susann Sanchez and LPA Joshua Ortgea arrived to the facility and met with Licensee Robin Henderson, Licensee gave LPAs a tour of the facility including "off limit" areas. The purpose of the clearing deficiencies that were cited on 07/10/24.

The following was observed:
  • At 1:35pm, while touring "off limit" areas, Licensee stated and admitted that adult #1 was present in bedroom #3. Adult #1 was cited on 07/10/24, for not having fingerprint clearance. As of today 08/02/24, Adult #1 is still pending fingerprints. An immediate violation and repeated violation was cited.
  • At 1:50pm, LPA observed the LIC 9224 "Acknowledgement of Receipt of Licensing Reports" for the children present during today's inspection.
  • At 1:40pm, LPA observed current CPR & 1st Aid and expires on 07/2026. LPA cleared citation.
  • At 2:14pm, LPA observed sleep logs for two infants between 07/15/24 to 08/02/24. LPA cleared citation.

The following deficiencies listed on the attached LIC 809-D (deficiency page) are being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 1 and Section CCR & H&S.

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). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.

An exit interview was conducted with Licensee Henderson. Appeal Rights and Notice of Site visit was given.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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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Document Has Been Signed on 08/02/2024 03:02 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: HENDERSON FAMILY CHILD CARE
FACILITY NUMBER: 198019922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
102370(k)

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The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility. This requirement is not met as evidenced by: At 1:35pm, while touring "off limit" area, Licensee stated
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This is a repeated violation. Per Licensee, adult #1 did their live scan on 07/12/24. Per Licensee thought adult #1 fingerprints had cleared. Licensee informed indivudal to leave and stay with another family memeber. LPA's advised Licensee to avoid interaction with children when exiting.
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and admitted that adult #1 was present in bedroom #3. Adult #1 was cited on 07/10/24, for not having fingerprint clearance. This poses an immediate health, safety or personal rights risk to 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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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