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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006396
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:08:57 PM

Document Has Been Signed on 07/28/2023 01:08 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
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: 2DATE:
07/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee - Annette ThomasTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Randy Derraco conducted an unannounced case management visit to the above mentioned facility on 07/28/23. LPA arrived at the facility at 10:30 AM and was met by licensee, Annette Thomas, who guided analyst on a tour of the facility. LPA observed 2 children in care upon arrival. No additional adults were observed in the home. The reason for this visit is in relation to the incident that occurred on 05/07/23 and the issuance of the exclusion order dated 07/26/23, confirming the the Licensee's son has been removed from the premises.

This is a one-story home which consists of four bedrooms, two bathrooms, kitchen/dining room, living room, a detached garage, front yard and backyard (fenced). The off limit areas include 3 bedrooms, 1 bathroom, living room, dining room, kitchen, detached garage front yard and back yard.

During the inspection, LPA observed that the home is currently undergoing a remodel project in the off limits kitchen, bathroom, dining room and living room. This remodel project was originally discussed during a required one year annual inspection dated 03/27/23. The main care area is currently located in bedroom one. A futon couch, age appropriate toys, children's reading material, child sized table with chairs were observed in the main care area. The bathroom designated for children's use was observed to be sanitary with an operable sink, faucet and toilet. LPA explained that a Type A citation under California Code of Regulation (CCR) section 102402(a)(3) is being issued. LPA advised licensee that the nature of the incident that occurred on 05/07/23 is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. On 07/26/23, the licensee was served an exclusion order for the adult son excluding him from the facility. Licensee has stated that the adult son has been removed from the home.

A copy of the LIC995B was provided during this visit. Licensee has been advised that this is to be signed by
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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Document Has Been Signed on 07/28/2023 01:08 PM - It Cannot Be Edited


Created By: Randy Derraco On 07/28/2023 at 11:42 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: THOMAS FAMILY CHILD CARE
FACILITY NUMBER: 192006396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
102402(a)(3)

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102402 Revocation or Suspension of a License or Registration(a)The Dept shall have the authority to suspend or revoke any license...(3)Conduct in the operation...of a family day care home which is inimical...This requirement is not met as evidenced by:
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Licensee states that she will complete a declaration (LIC855) indicating that her son Cedric has been removed from the premises, that date he was removed, and his current address. An LIC 855 will also be completed by Cedric's father confirming Cedric is living with him.
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On 5/7/23 the Licensee’s adult son was arrested for conduct which is inimical to the health, morals, welfare or safety of...an individual in or receiving services from the facility... This poses an immediate health, safety and/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:Karen Chambers
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: THOMAS FAMILY CHILD CARE
FACILITY NUMBER: 192006396
VISIT DATE: 07/28/2023
NARRATIVE
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each parent/guardian of children currently enrolled as well as any newly enrolled children. Failure to meet this requirement will result in a $100.00 civil penalty per family.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility. Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

Exit interview conducted with the Licensee, during which appeal rights were explained. 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: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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