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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401365
Report Date: 06/23/2022
Date Signed: 06/09/2023 10:41:00 AM

Document Has Been Signed on 06/09/2023 10:41 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:COLEMAN FAMILY DAY CAREFACILITY NUMBER:
197401365
ADMINISTRATOR:COLEMAN, KELLY JOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 296-3229
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 2DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Kelli Coleman- LicenseeTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Keyona Scott, conducted an unannounced Annual Required Inspection on 06/23/2022. LPA met with Adult 1 at 2:25 PM. Licensee, Kelli Coleman, was called by Adult 1 and arrived at facility at approximately 2:30 PM. During today's inspection, LPA observed one child and one infant in care. Per Licensee, children are siblings; however, infant is not enrolled due to providing care for children as a last minute favor to family friend. All adults present, residing, working and/or volunteering in the home home have a criminal record clearance or exemption. There are no excluded individuals present at the home. Per Licensee, childcare is not conducted on a regular, daily basis.

LPA toured the inside and outside of the home. The home is two stories with five bedrooms, two and a half bathrooms, kitchen, family room, living room, laundry room and attached garage. Per Licensee, no childcare is conducted in the attached garage. Licensee confirmed that the family room located through the hallway to the rear of the home is the primary childcare area. LPA observed kitchen playset, push carts, ball, bike, blocks and other age appropriate toys in the childcare area. All bedrooms in the home and the bathroom located upstairs are off-limits and made inaccessible to children in care by use of closed and/or locked doors during operation hours. LPA observed a gate at the bottom stairwell entrance to the second floor of the home.

LPA did not observe pool, spa, hot tub or other similar bodies of water on the premise.
Per Licensee, there are no firearms, ammunition or weapons on the premise; none were observed by LPA. Page 1
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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 06/09/2023 10:41 AM - It Cannot Be Edited


Created By: Keyona Scott On 06/23/2022 at 04:13 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY DAY CARE
FACILITY NUMBER: 197401365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Keyona Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY DAY CARE
FACILITY NUMBER: 197401365
VISIT DATE: 06/23/2022
NARRATIVE
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All poisons are locked. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There is at least one working fire extinguisher, smoke detector and carbon monoxide detector in the home. Centralized heat and air conditioning along with ceiling fans are utilized as heating and cooling sources.

The home has working telephone service and LPA confirmed the phone number is on file.

The outdoor play area is conducted at a local park. LPA advised Licensee, if children are transported to the park to have parent/authorized representative sign an agreement of consent and place in child's physical file. LPA also advised Licensee that a copy of the transporter's driver's license and insurance is to be placed on file at the facility. Licensee ensures that children in care, are supervised at all times and is aware children shall not be left in parked vehicles.



Licensee completed Mandated Reporter training on 06/30/2020. LPA advised Licensee that Mandated Reporter training is to be renewed every two years and certificate of completion is to be placed in each employee's physical file.

LPA observe Emergency Disaster Plan posted at the entrance of facility.

Per Licensee, Licensee's CPR/First Aid certification expired in May 2022. Adult 1 and Adult 2, who were present alone in the household with children in care, while Licensee was away from home, also did not have current CPR/First Aid certification. Failure to renew CPR/First Aid certification, causes a potential health, safety or personal rights risk to persons in care.
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY DAY CARE
FACILITY NUMBER: 197401365
VISIT DATE: 06/23/2022
NARRATIVE
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The facility was not operating in substantial compliance during today’s inspection on 06/23/2022. Facility was cited for one (1) Title 22, Division 12, Chapter 3, of the California Code of Regulations. Facility was also provided several Technical Violations. This will be discussed upon inspection continuation for a future date.

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

Exit interview conducted and report was reviewed with the Licensee, Kelli Coleman.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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