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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400272
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:37:20 PM

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:DOHERTY FAMILY CHILD CAREFACILITY NUMBER:
198400272
ADMINISTRATOR:ERENDIRA DOHERTYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 841-7732
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:14CENSUS: 10DATE:
12/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Erendira DohertyTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management Incident inspection. This inspection is regarding injury incident that took place on December 14, 2021. Licensing Program Analyst met with Licensee Erendira Doherty and cleared assistant who providing information and assistance for the inspection. Two non-daycare minors were also present.

Licensee guided Analyst to the daycare room and Analyst observed the door where child #1 was injured. LPA observed the area to be clean, free of hazards and appearing to be in normal good condition. Licensee indicates there was eight (8) children in care at the time of the incident (1 infant and seven preschool). . Licensee and staff #1 indicate they were providing care on the date of the incident. Licensee indicated she was in the room with the children when the incident took place. Staff #2 indicates he/she was in another area of the house getting the children snacks when the incident took place. Child #1 was given first aid immediately after the incident occurred. After the child was given first aid, the child's parents were contacted.

Note: The child was taken to the doctor for medical treatment. Staff followed the required protocol in terms of first aid and "reporting requirements" as the 12/14/2021 incident was reported to Child Care Licensing within the required 24 hours (reported the same day). LPA provided Licensee with a ratio and capacity handout regarding ratio and capacity and care and supervision.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Licensee Erindira Doherty..
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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