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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407320
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:08:24 PM

Document Has Been Signed on 03/25/2022 04:08 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.FACILITY NUMBER:
197407320
ADMINISTRATOR:PEGGY NAIRNFACILITY TYPE:
830
ADDRESS:9213 COLUMBUS AVENUETELEPHONE:
(818) 892-6634
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 10DATE:
03/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Susan GlamuzinaTIME COMPLETED:
04:20 PM
NARRATIVE
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On 03/25/2022 at 8:25 a.m., Licensing Program Analysts (LPAs) Silva Garibyan and Antonio Almanza conducted an unannounced Case Management Visit at the Probationary Licensed Facility. During today’s visit LPAs met with the Director, Susan Glamuzina, explained the purpose of the visit and toured that facility. During today’s visit there were 3 adults providing care and supervision to 10 children in care.

The Director is reporting that the Columbus Child Care Combination Center, located at 9213 COLUMBUS AVENUE, NORTH HILLS, CA 91343 operates 24-hours per day, Sunday through Saturday. All Adults in the facility have received criminal record clearance and are associated to the facility. LPAs verified the facility phone number is (818) 892-6644. Prior to entering the facility, LPA Almanza attempted to conduct a COVID-19 Risk Assessment by calling the facility phone number 3 times, but no one answered the phone. It was explained to the Director the importance of the facility Director or staff attending to the phone, because the call may be related to an emergency that can affect the Health and Safety of Children in Care.
During todays visit the following violations are being cited under Title 22 Regulations, Division 12, Chapter 1, of the California Code of Regulations, and Health & Safety Code (please see LIC 809-Ds for cited deficiencies).

1. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, Staff 1 is the Director of the Columbus Child Care Center location on Saturday. Based on the Documents provided by Peggy Nairn, Staff 1 does not have the qualifications required to be the Director.

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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320
VISIT DATE: 03/25/2022
NARRATIVE
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2. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, Staff 2 is the Director of the Columbus Child Care Combination Center location Monday through Saturday, 9:00 p.m. to 6:00 a.m. Based on the Documents provided by Peggy Nairn, Staff 2 does not have the qualifications required to be the Director.

3. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, there is no Director scheduled at the Columbus location Sunday through Friday 6:00 a.m. to 9:00 a.m., and Sunday 6:00 a.m. to 12:00 p.m.

4. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn and the information provided by staff, the persons assigned as the child care center directors during the evening, night and weekends are assigned classroom teachers. There is no Actual Director on site during these times. The evening, night and weekend Directors are assigned to classroom as teachers when they are supposed to be the Director.

5. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn, Licensee has not provide 24 hours of quarterly training to staff on mental health assessments, client behaviors, personal rights, care and supervision, and medication and keep a record of staff who attend such training and make records available to Licensing.

6. Per Stipulation Waiver; and Order no staff shall not work more than 8 hours per day, Based on information provided by staff, Facility Staff have been working over 8 hours per day.

7. LPA’s observed Cleaning supplies next to the sink in the bathroom located inside the Infant room. The bathroom door is not kept locked and is accessible to older infants that are able to walk (Violation was corrected during the visit)

8. Per records review and information provided by staff, 2 of the 10 infants in the facility are enrolled in the Infant Center located at the Dearborn location facility # 197407810, and are taken to the Dearborn location around 9 am every day.

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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320
VISIT DATE: 03/25/2022
NARRATIVE
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During todays visit two Civil penalties for repeat violation were issued. Please see LIC421FCs

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of LIC 9224 was provided to Director Susan Glamuzina.

A copy of this Report (809 & 809Ds) and appeal rights were explained and provided to the Director Susan Glamuzina and Administrator Tammy Jacquin. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.












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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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Page: 5 of 7
Document Has Been Signed on 03/25/2022 04:08 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/25/2022 at 01:12 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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101215.1(h)(1)

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101215.1(h)(1) Child Care Center Directors Qualifications and Duties, High school graduation or GED; completion, with passing grades, of 15 semester or equivalent quarter units as specified in (h)(1)(A) and (h)(1)(B) below at an accredited or approved college or university...
This requirement is not met as evidenced by:
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Liensee will provide veification of Director Qualifications to the LPA by 04/01/2022 or find a Replacement for the Director.
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Based on records review, Staff 1 does not have the qualifications to be Director, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited
CCR101415(c)

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101415(c) Infant Care Center Director Qualifications and Duties, At least three of the semester or equivalent quarter units required in Sections 101215.1(h)(1)(B), (h)(2) and (h)(3)...

This requirement is not met as evidenced by:
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Liensee will provide veification of Director Qualifications to the LPA by 04/01/2022 or find a Replacement for the Director.
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Based on records review, Staff 1 does not have the qualifications to be Director, which poses a potential Health or Safety, 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


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Page: 3 of 7
Document Has Been Signed on 03/25/2022 04:08 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/25/2022 at 01:27 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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101215.1(d)

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101215.1(d) Child Care Center Directors Qualifications and Duties, The child care center director, or the substitute director as specified in (f) below, shall be on the premises during the hours the center is in operation.
This requirement is not met as evidenced by:
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Licensee will submit an updated Personnel Record Lic500 demonstrating that there is a Director During the hours the Child Care Center is in operation.
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Based on observation and records review, The Licensee does not have a Director assigned to the Facility During all hours of operation, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited
CCR101215.1(c)

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101215.1(c) Child Care Center Directors Qualifications and Duties,The child care center director shall be responsible for the operation of the center, for compliance with regulations, and for communications with the Department...

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Licensee will make sure to have a Director assigned to the Evening and Night programs that is not in the classroom as a teacher. Licensee will provide copy of Personnel Roster with proper staffing for the facility during the programs.
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Based on interviews, The Licensee does not have a Director During the Evening and Night progrmas, which poses a potential Health or Safety, or personal rights risk to persons in care.
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 Licensee will provide copy of Personal Roster with proper staffing for the facility during the programs by 04/01/2022.
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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


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Document Has Been Signed on 03/25/2022 04:08 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/25/2022 at 01:56 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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101216(e)

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101216(e) Personnel Requirements, All personnel shall be given on-the-job training... Per Stipulation Licensee shall provide 24 hours of quarterly training and keep a record of staff who attend such training and make records available to Licensing.1596.881 and 1596.882 of the Health and Safety Code Personnel Requirements (l) All personnel shall be informed of their rights… Staff 5 is reporting that she has worked more than 8 hours.
This requirement is not met as evidenced by:
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Licensee shall comply with the Stipulation and Waiver; and Order, and provide the 24 hours of training to staff and submit a copy of the records of staff who attended the training on required subjects to LPA by 4/01/22.
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Based on observation and records review, The Licensee does not have records available for the 24 hours of quarterly training, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited
CCR101216(l)

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101216(l) Personnel Requirements (l) All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code.

This requirement is not met as evidenced by:
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Per Stipulation no employee shall work more than eight (8) hours per day. The director shall immediately ensure that no staff is working more than 8 hours per day.
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Based on records review staff have been working more than 8 hours, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Director will provide LPA with copy of the staff time cards from 03/01/2022 to 03/25/2022 and provide a Mitigation Plan demonstrating how the facility will ensure to be fully staffed at all times and that no employee shall work more than eight (8) hours per day by end of day 4/01/22
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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/25/2022 04:08 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/25/2022 at 02:17 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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
101238(g)(1)

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101238 Buildings and Grounds(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.(1) Storage areas for poisons shall be locked.
This requirement is not met as evidenced by:
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The Staff bathroom located in the infant room has been made inaccessible with safety latch.
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Based on observation, Cleaning supplies and chemichals were not inaccessible, which poses a potential Health or Safety, 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


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