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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006396
Report Date: 08/01/2023
Date Signed: 08/07/2023 11:04:29 AM

Document Has Been Signed on 08/07/2023 11:04 AM - 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 S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:THOMAS FAMILY CHILD CAREFACILITY NUMBER:
192006396
ADMINISTRATOR:THOMAS, ANNETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 422-7177
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 0DATE:
08/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee - Annette ThomasTIME COMPLETED:
10:35 AM
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On August 1, 2023 at 10:00AM, Regional Manager Sharon Green, Licensing Program Manager Karen Chambers, Licensing Program Manager Denise Gibbs and Licensing Program Analyst Randy Derraco conducted a virtual Noncompliance Conference via Microsoft Teams with Licensee Annette Thomas.

The purpose of this visit is to discuss whether or not the licensee plans to comply with the immediate exclusion order dated July 26, 2023 with regards to the licensee's son, Cedric Thomas, Type A citation issued on 07/28/23, appeal rights for Cedric Thomas and Annette Thomas. RM Sharon Greene advised licensee the exclusion letters was sent both by regular and certified mail to the address provided by the licensee. According to the licensee, Cedric has not yet received the letter but will confirm.

Licensee agrees comply with the immediate exclusion order dated July 26, 2023 for her son Cedric Thomas. The licensee will provide a declaration from Cedric's father, declaring Cedric currently lives at his residence and the effective date. Per licensee, she has given the document to Cedric's father on 07/28/23.

Licensee was advised that an unannounced follow up visit will be made within the next 30 days to ensure that Cedric Thomas is no longer at the facility

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 licensee, Annette Thomas. A copy of the appeal rights (LIC9058 03/22) were provided. The Licensee’s signature on this report acknowledges receipt of her rights.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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