<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006396
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:05:08 PM

Document Has Been Signed on 08/07/2023 12:05 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: 1DATE:
08/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee - Annette ThomasTIME COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing program analyst (LPA) Randy Derraco conducted an unannounced case management visit on 08/07/23. LPA arrived at the facility at 9:30 AM and was met by licensee, Annette Thomas who guided the analyst on a tour of the facility. The purpose of this visit is to obtain signatures on LIC 9111 and LIC 809 documenting a Noncompliance Conference held on 08/01/23. During the visit, LPA observed 1 adults and 2 children. One child was observed to be under the care of the facility. Licensee states that S3 and S4 have been living in the home for over a year and are usually in school. Both S3 and S4 have just finished summer school and are now at home. Licensee explained that she was unable to get fingerprints completed for S4 because she does not have identification. Licensee states that S4 had a California Identification card application completed in July 2023 and is expecting the card in the mail. LPA advised licensee that a Type A citation under California Code of Regualtion (CCR) section 102370(d)(1) will be issued. Licensee was advised that a Civil Penalty in the amount of $500 will be assessed.

LPA Randy Derraco informed licensee Annette Thomas that this report dated 08/07/23 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Randy Derraco informed the licensee Annette Thomas to provide a copy of this licensing report dated 08/07/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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, appeal rights provided, and report was reviewed with the licensee Annette Thomas

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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 2
Document Has Been Signed on 08/07/2023 12:05 PM - It Cannot Be Edited


Created By: Randy Derraco On 08/07/2023 at 11:37 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: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/08/2023
Section Cited
CCR
102370(d)(1)

1
2
3
4
5
6
7
102370 Criminal Record Clearance (d) All individuals subject to a criminal record review...shall prior to working, residing, or volunteering in a licensed facility (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will have S4 fingerprinted and associated when her California Identification card arrives in the mail.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not obtain criminal record clearance for S4 which poses an immediate Health, safety and/or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2