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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411753
Report Date: 03/19/2025
Date Signed: 03/19/2025 02:45:24 PM

Document Has Been Signed on 03/19/2025 02:45 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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:POLK FAMILY CHILD CAREFACILITY NUMBER:
197411753
ADMINISTRATOR/
DIRECTOR:		POLK, CHARLOTTE ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 200-8718
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:23 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 03/19/25 Licensing Program Analyst (LPA) Portia Bowden conducted an unannounced Annual Inspection at the above facility. At 1:20PM LPA met with Assistant Mikeysha and Assistant Marissa who stated Licensee Charlotte was doing transportation. LPA provided entrance check list and conducted a tour of the home. LPA observed 4 children napping during inspection. At 1:30PM Licensee arrived with 9 additional school aged children. Per Licensee there are 15 children currently enrolled. Per Licensee hours of operation are 24 hours. LPA reminded Licensee that care may never exceed 23 hours. Per licensee she is apart of the food program and provides Breakfast, AM Snack, lunch, and PM Snack. Per Licensee outside food is permitted in the facility. LPA reminded Licensee that all outside food brought in should be labeled and dated. Per licensee, overnight care and transportation to and from school are provided. LPA observed all appropriate documents on licensing board (Facility License (LIC 203), Emergency Disaster Plan (LIC610a), ER drill log last dated 2/25, Notification of Parents' Rights Poster (PUB 394), Child Care Facility Roster (LIC9040). LPA observed Current Mandated Reporter certificates for both assistants and an expired certificate for Licensee. Per Licensee she will obtain a current certificate and submit to LPA via email. A type B deficiency will be issued. LPA observed Assistant Marissa’s current Pediatric CPR/First Aid Certification with an expiration date of 3/27 Per Licensee there are no children in care with food allergies and 1 child who requires IMS. Per Licensee she does not administer medication, she calls parent of child to pick up in the event he requires his inhaler.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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Document Has Been Signed on 03/19/2025 02:45 PM - It Cannot Be Edited


Created By: Portia Bowden On 03/19/2025 at 02:22 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in fire extinguisher was last serviced 12/23 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee will have fire extinguisher serviced or purchase a new one and submit proof to LPA via email
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not ensure staff files were complete in 1 out of 3 staff had an expired Mandated Reporter Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee will obtain a current Mandated Reporter Certificate and submit to LPA via email.
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:Portia Bowden
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753
VISIT DATE: 03/19/2025
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This is a one-story home consisting of 3 bedrooms, 4 bathrooms, living room, kitchen, den, enclosed front and backyard and an attached converted garage. Per Licensee areas used by the children include living room, Den (main daycare room), one bathroom located in the den, 1 bedroom, and enclosed front yard. Per Licensee areas off limits to children and parents include 2 bedrooms, 3 bathrooms, enclosed backyard and attached garage.

Per Licensee there are no poisons on the premises. Per licensee detergents, are kept in the offlimit garage, inaccessible to children LPA observed a safety latch making it inaccessible to children in care. Per licensee medication is stored in an off limit bedroom inaccessible to children in care. At 1:45PM LPA observed a fully charged 2A10BC fire extinguisher on the kitchen wall with a service tag dated 12/23, per Licensee she will have it serviced immediately, a Type B deficiency will be issued. At 1:50PM LPA observed a functioning smoke detector and carbon monoxide unit on the ceiling of the living room. The home was observed to have proper ventilation and heating for safety and comfort. LPA observed no wall heaters or fireplaces. The home maintains telephone service via cell phone. Per licensee there are no firearms on the premises.

Kitchen area was observed to be clean and free of clutter and have no sharp objects or chemical compounds accessible to children in care. At 1:55PM LPA observed kitchen knives stored in a high kitchen cabinet, inaccessible to children in care. Bathroom children was observed to be clean and free of hazards. LPA observed no sink cabinet in the bathroom. Per Licensee she provides potty training.

LPA observed adequate toys and age appropriate learning materials in the den as well as mats for sleeping. Per Licensee all linens are washed weekly and as needed by facility.

Outdoor Play for children in care is located in the enclosed front yard. At 1:55PM LPA observed the area to be fully enclosed with proper shading. No bodies of water were observed on the premises.

3 children’s file was reviewed and observed to be complete.

3 Staff files and observed to be complete

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753
VISIT DATE: 03/19/2025
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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 or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA 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.

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: https://www.ada.gov/resources/child-care-centers/.



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.

During the exit interview, Licensee Charlotte Polk, confirmed there are no Registered Sex Offenders living in the home. LPA completed the RSO profile in FAS.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753
VISIT DATE: 03/19/2025
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Two Type B Deficiencies were observed during today’s inspection for expired mandated reporter certificate and expired fire extinguisher.

Exit interview conducted with Licensee Charlotte Polk, copy of this report, appeal rights, and a notice of site visit were provided.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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