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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197410498
Report Date: 07/18/2025
Date Signed: 07/18/2025 12:30:03 PM

Document Has Been Signed on 07/18/2025 12:30 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:COLBY-MARTIN FAMILY CHILD CAREFACILITY NUMBER:
197410498
ADMINISTRATOR/
DIRECTOR:		COLBY-MARTIN, KENISHIA S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 753-8308
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
07/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Kenishia Colby-Martin, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 07/18//2025, Licensing Program Analyst (LPA) Dawn Dowling conducted an unannounced case management incident inspection due to an incident which occurred on 07/08/2025. The written report was emailed and received to the Regional Office on 07/09/2025.. LPA Dowling arrived at the facility and met with Licensee Kenishia Colby-Martin

Census: 9 children and 2 Staff( Licensee and Assistant).

7/8/2025 it was reported that while on a supervised walk with 12 classmates and 2 staff, Child #1 began to race playfully back to campus. While running, child's tennis shoe came off, causing him to loose his balance, he fell forward, striking his head and landing on his shoulder. Staff immediately picked him up and carried him halfway back to the school before allowing him to walk/run the remainder of the way with his peers.

Upon returning to school. Child was provided with ice for his injuries. Child's parent was contacted and arrived shortly thereafter with Tylenol for pan relief. Child was taken to Kaiser Hospital, where X-rays confirmed a broken Clavicle.

During staff interview LPA Dowling was informed that both staff had active supervision of the child who obtained an injury. LPA Dowling inspected where the incident occurred, the sidewalk is smooth, no cracks or broken concrete that would cause a fall.(LPA took photos of pavement) LPA Dowling was informed that children were returning from nature walk, getting ready to race back to school.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: COLBY-MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 197410498
VISIT DATE: 07/18/2025
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Child #2 that was next to child #1 pushed past him after hearing,"On your mark, get set go." which caused child #1 to loose his balance and fall out of his shoes( he was wearing tennis shoes with Velcro closures) that were not very secure which caused him to come out of the shoes when he lost his balance.

When Child # 1 lost his balance he fell onto the pavement causing him to injury himself. Assistant was behind child #1 and immediately went to him and picked him up, checked for injuries. Child# 1 was crying.

Child#1's Grandfather was outside (he lives a few houses down the street) saw what happened and went over to child #1 ,inspected child said "He's alright." and child went back to child care home with staff and peers. Upon arrival to child care home child# 1 was given ice pack, placed on his head, both of his shoulders and arm due to child falling forward and not knowing the exact area of the injury as it appeared it may have been his head.

Child #1 Mother was notified and she arrived to child care home at 11:15 AM giving child #1 Tylenol for pain relief. Mom observed child and indicated he was alright, he remained in care the remainder of the day.

Licensee kept watch on child #1 due to child off and on. Child ate very little during lunch time and was keeping to himself during playtime, unable to nap during naptime getting up at 2:15 PM. Licensee spoke with child #1 due to child saying , "it hurts, it hurts."

Licensee tried to determine where child's pain was coming from as child was saying arm and pointing to shoulder, lifted up shirt and noticed a bump on child's left shoulder. Licensee took a picture and informed child's parent that due to child's discomfort and crying of and on that perhaps injury needs to be checked out to ensure that it is not serious as child is not a crier and it was not like child to cry. Licensee provided LPA Dowling with photograph of bump on child's left shoulder.

Parent picked up child #1 at 4:30 PM and parent later took child to Kaiser Hospital where child obtained X-ray that confirmed child had broken clavicle. Child stayed home and returned to school on 7/11/2025. Child has a sling to keep arm propped up. Licensee has assisting child with sling by putting safety pin to the sling and T-shirt to ensure arm is kept up. Child had a follow-up visit with Doctor on 7/14/25, per Parent the follow up visit indicated thing are going well with recovery. The recovery process will be 6-8 weeks and Doctor recommends to try to keep child off the playground, prop arm up to keep it stationary. LPA Dowling observed child to be engaging with peers and staff without any issues.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: COLBY-MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 197410498
VISIT DATE: 07/18/2025
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During today's inspection, LPA conducted interview, obtained photograph of child#1 shoulder after accident, observed the location of accident(took photograph)

Based on information obtained, no further investigation is needed.

An exit interview was conducted with Licensee, Kenishia Colby-Martin. A copy of this report (LIC 809) and Notice of Site Visit were provided and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
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