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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191599616
Report Date: 05/28/2026
Date Signed: 05/28/2026 01:19:33 PM

Document Has Been Signed on 05/28/2026 01:19 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PACHECO FAMILY DAY CAREFACILITY NUMBER:
191599616
ADMINISTRATOR/
DIRECTOR:		PACHECO, PAULA SFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 698-7738
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 12TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
05/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee, Paula PachecoTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lilli Babcock conducted an unannounced annual inspection to the above facility. LPA met with Licensee, Paula Pacheco, to whom the reason for the visit was explained. Per Licensee, there are five children currently enrolled. There were three children, Licensee, and assistant, present upon arrival. The licensee was observed to be operating within the license capacity limitations.

The licensee states that four adults and one child currently live on the premises. All adults living on the premises have obtained a criminal record clearance.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, dining room, kitchen, living room, playroom, and a one bedroom, one bathroom ADU in the backyard which is used for fingerprinted adult and child to reside in, front yard, and backyard which is fenced.

Per licensee, areas off-limits to children and parents include 3 bedrooms, 1 bathroom, detached ADU, and a portion of the backyard and the entire front yard. The children have access to kitchen, dining room, living room, one bathroom, playroom, and a sectioned off portion of the fenced backyard (closest to the back fence).
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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616
VISIT DATE: 05/28/2026
NARRATIVE
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Licensee guided analyst on a tour of the facility. During this visit, all areas identified on the facility sketch that are accessible for children to use were toured and inspected and the following was observed.

Facility License, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the entryway of the home. A current children’s roster was available for review.

There is telephone service via a cellphone and landline. Hours of operation are Monday – Friday, 6:45 am - 5:00 pm. Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee, there are no poisons at the facility, and none were observed on this day. LPA advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms, weapons, bodies of water, or fireplaces on the premises, and none were observed on this day.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 10/1/25, as indicated on the service tag. Smoke and carbon monoxide detectors were tested and were operable on this day.

All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 4/2/26.

The home is observed to be clean and orderly. There are first aid supplies available. There are age-appropriate toys available for children. Licensee states that she is currently caring for one infant. LPA observed a sleep log for the infant.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616
VISIT DATE: 05/28/2026
NARRATIVE
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Currently, children are using a sectioned off portion (by back fence of property) of the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. No bodies of water were observed on this day.

Children’s records were reviewed, including emergency information. LPA reviewed files for all 5 children enrolled. LPA observed Child #1 and Child #2 were missing the LIC 700, and LIC 627, Child #1 was missing proof of immunizations, Child #1, #2, #3, and #5 were missing LIC 995A, and Child #1, #2, and #3 were missing an LIC 282. Licensee records were reviewed. Mandated Reporter AB 1207 compliant Child Care Training for Licensee and Assistant expires 10/17/26. Pediatric Fist Aid/CPR with American Heart Association for Licensee and Assistant expires 10/12/26. LPA observed Licensee does not have proof of immunity to measles for assistant.

LPA issued an LIC 857, Children’s Record Review, and LIC 859, Staff Record Review to the licensee which documents staff and children’s files reviewed during this inspection.

Per Licensee there is one cat on the premises. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family child care facility.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616
VISIT DATE: 05/28/2026
NARRATIVE
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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 of the importance of checking for and removing any 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 PIN 22- 02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Paula Pacheco, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
Page: 5 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616
VISIT DATE: 05/28/2026
NARRATIVE
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questions regarding the process or CARE tools, please send email inquiries 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/inspection-process.

Based on LPA observations, interviews, and records review, the following deficiencies listed on the attached LIC 809D (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 and safety.

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



Exit interview conducted and report was reviewed with the licensee Paula Pacheco.



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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/28/2026 01:19 PM - It Cannot Be Edited


Created By: Lilli Babcock On 05/28/2026 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026

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
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3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 2 Licensee and staff files reviewed which did not contain proof of measles immunity for assistant (Staff #2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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2
3
4
Licensee will obtain proof of immunity to measles for assistant (Staff #2)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on interview and record review, the licensee did not comply with the section cited above in one out of five children's files reviewed. Licensee did not have proof of immunizations for Child #1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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2
3
4
Licensee will obtain proof of current immunizations for Child #1.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 05/28/2026 01:19 PM - It Cannot Be Edited


Created By: Lilli Babcock On 05/28/2026 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 5 children's files reviewed which did not have a completed LIC 700 form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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Licensee will obtain a completed and signed LIC 700 form and LIC 627 form for Child #1 and Child #2.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 05/28/2026 01:19 PM - It Cannot Be Edited


Created By: Lilli Babcock On 05/28/2026 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 5 children's filed reviewed which did not contain a signed and completed LIC 995A, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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2
3
4
Licensee will obtain a signed and completed LIC 995A for Child #1, #2, #3, and #5.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 05/28/2026 01:19 PM - It Cannot Be Edited


Created By: Lilli Babcock On 05/28/2026 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACHECO FAMILY DAY CARE
FACILITY NUMBER: 191599616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 5 children's filed reviewed which did not contain a completed and signed LIC 282, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
1
2
3
4
Licensee will obtain a completed and signed LIC 282 for Child #1, #2, and #3.
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
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 infants without a completed and signed LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
1
2
3
4
Licensee will obtain a completed and signed LIC 9227 for Child #1.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
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