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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197410321
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:10:17 AM

Document Has Been Signed on 10/03/2023 11:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:COLEMAN FAMILY CHILD CAREFACILITY NUMBER:
197410321
ADMINISTRATOR:COLEMAN, KNAKHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 290-3737
CITY:LOS ANGELESSTATE: CAZIP CODE:
90008
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 2DATE:
10/03/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Licensee Knakhea ColemanTIME COMPLETED:
11:30 AM
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On 10/03/2023 at 8:10 am, Licensing Program Analysts (LPA) Maria Rendon met with Licensee, Knakhea Coleman and guided LPA on a tour of the home. The purpose of the visit was an unannounced annual inspection continuation visit to follow up on annual inspection conducted on 9/28/23 at the home to ensure that health, safety and personal rights as requires by Title 22 and Health and Safety Regulations governing California Child Care Homes will be met. The Family Child Care Home operates Monday-Sunday 6:00 am -5:59 am. LPA observed 2 child in care under the care and supervision of Licensee and 01 other staff member (S1).

During today’s visit LPA Rendon addressed the deficiencies that were observed on 9/28/23.

On 9/28/23 during the tour of the facility LPA observed two infant children (C1) and (C2) and each infant child was sleeping in their own play yard. LPA observed C1 to have a pacifier that was attached to C1’s clothing and in the play yard LPA observed a pillow, teething toy, baby bottle, a loose sheet, and a blanket, which poses an immediate Health and Safety, or Personal Rights risks to person in care (pictures were taken). LPA observed C2 face down while sleeping, C2 was observed with a bib while sleeping and in the play yard LPA observed soft toys, a small stuffed animal, and teething toys, which poses an immediate Health and Safety, or Personal Rights risks to persons in care (pictures were taken). LPA discussed and provided licensee with Provider Information Notification PIN 20-24-CCP and Infant Safe Sleep Regulation 102425.

On 9/28/23, licensee was not able to provide the facility roster which poses a potential Health and Safety, or Personal Rights risk to persons in care.

On 9/28/23, LPA reviewed 6 children’s files and found children’s files were incomplete with immunization records and two children in care did not have files.

pg 1 of 5

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Maria Rendon
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321
VISIT DATE: 10/03/2023
NARRATIVE
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On 9/28/23, licensee was not able to provide individual sleeping plans and documentation of 15-minute safe sleep checks.

On 9/28/23, LPA reviewed staff files and found staff files to be incomplete. In the staff files LPA observed LIC 9108, LIC 9052, and Mandated Reporter Certificate. Documents that were missing were current immunizations for S1. Licensee and S1 did not have a current Pediatric CPR and First Aid Certification issued by American Heart Association.

LPA toured the home inside and out. Currently facility sketch reviewed and Licensee confirmed that the day care room is located in the back of the house and bathroom near the day care is accessible to children in care. All other areas, living room, dining room, two bedrooms, laundry room, kitchen, and pantry were observed to be inaccessible to children in care using children proof doorknobs, child gates and supervision. The bathroom accessible to children was observed to be clean with toilet and faucet safe and operable.

LPA observed two working smoke detectors located in the hallway, and day care area. Carbon monoxide was observed in the hallway.LPA was able to hear a successful test for both carbon monoxide and smoke detector. LPA observed fire extinguisher 3-A:40-B:C located on the wall in the daycare room. Electrical outlets were observed to be inaccessible to children in care with the use of plug covers. The home was observed to be clean and orderly with heating and ventilation. LPA observed safe toys, play equipment, and materials. LPA verified the home has a working telephone service. LPA observed poisons, detergents, cleaning compounds, medicines, and hazardous items that pose a danger to children to be made inaccessible. First Aid kit was observed and complete. Per LIS the facility annual fees are current.

Mats were observed for napping. Two play yards observed to be available for infants in care.

Kitchen was observed with sharp utensils and are inaccessible. Kitchen was observed to be clean. Licensee provide all foods to the children.

Outdoor area is located in the back yard. Outdoor area was observed to be fenced in. LPA observed the outdoor area and there are no hazards to children present.

There are no firearms or ammunition on the premises. There are no bodies of water in the premises.

LPAs observed the following required postings: current facility license, LIC610A Emergency Disaster Plan, and PUB 394 Notification of Parents’ Rights Poster. pg 2 of 5.

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Maria Rendon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321
VISIT DATE: 10/03/2023
NARRATIVE
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LPA advised, fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Safety Commission shall not be used for children in care or accessible to children in care.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs advised smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

LPAs advised per CC Regulation 102417(a) Operation of A Family Child Care Home The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

pg 3 of 5

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Maria Rendon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321
VISIT DATE: 10/03/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

During the exit interview, the Licensee Knakhea Coleman, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



LPA Maria Rendon informed licensee Knakhea Coleman that this report dated 10/3/23 document 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 Maria Rendon informed the licensee Knakhea Coleman to provide a copy of this licensing report dated 10/3/23 that documents any Type A citation(s) to parents/guardian of all children currently enrolled by the next business day or the next day 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 child’s file for verification.

pg 4 of 5

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Maria Rendon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321
VISIT DATE: 10/03/2023
NARRATIVE
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Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

An exit interview was conducted with Licensee Knakhea Coleman. A copy of this report and Appeal Rights was provided to Licensee Knakhea Coleman

pg 5 of 5

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Maria Rendon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in 2 out of 2 infants sleeping in a play yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Have fitted sheets in each play yard. Read and follow infant safe sleep regulations.
Type A
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 infant having a pacifier attached to clothing and 2 play yards were observed with infants sleeping with loose articles and objects in the play yards which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Remove all loose articles and objetcs from play yards immediately, remove any attachment on the pacifier. Inform parents not to attach anything to pacifiers.
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(d)
Infant Safe Sleep
The provider shall place infants up to 12 months of age on their backs for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by 1 infant was observed not sleeping on their back which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Licensee Immediately placed infant in care on their back. Read and follow infant sleep regulations. Have in file Infant Safe Sleep Plan.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
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4
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in that S1 did not have immunization records in personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will request S1 to submit immunization records.
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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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in S1 and Licensee did not have current certficate for preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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4
Enroll in the training class to obtain certification in pediatric cpr and first aid issued by American Red Cross or American Heart Association or by approved Emergency Medical Services Authority (ESMA)
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above not having immunization records for S1 in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Licensee will request for S1 to provide immunization records.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 school age children did not have immunization records in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Licensee will ask parents to provide immunization records for children in care. Licensee will ensure that parents provide immunization records prior to enrollment to the daycare.
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a current roster of children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Create a roster for children in care and have it readily available and updated.
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having an individual infant sleeping plan LIC 9227 for C1 and C2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Licensee will provide parents of C1 and C2 and any other infant enrolled LIC 9227 and keep in child's file.
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 10/03/2023 11:10 AM - It Cannot Be Edited


Created By: Maria Rendon On 10/03/2023 at 09:20 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: COLEMAN FAMILY CHILD CARE
FACILITY NUMBER: 197410321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having documentation of 15 minutes sleeping log for C1 and C2 in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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2
3
4
Licnesee will have documentation of 15 minute sleeping log for evey infant in care in child's file.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Rita Ramos
LICENSING EVALUATOR NAME:Maria Rendon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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