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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416526
Report Date: 08/26/2025
Date Signed: 08/26/2025 02:31:19 PM

Document Has Been Signed on 08/26/2025 02:31 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:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
197416526
ADMINISTRATOR/
DIRECTOR:		JOHNSON, MARILYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 839-2498
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 12TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
08/26/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee, Marilyn JohnsonTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 8/25/2925 Licensing Program Analyst (LPA) Dawn Dowling conducted an unannounced Annual Required Inspection and met with Licensee, Marilyn Johnson. Days and hours of operation are Monday through Sunday, 24 Hour care.

LPA toured the inside of the home and a census was taken. An Entrance checklist (LIC 126) was provided to Licensee at the start of today's inspection. The home is a 2 bedroom 1 1/2 bathroom, Living Room, Dining Room, Den, Kitchen, Laundry Room, front and backyard. Licensee confirmed that the living room, den, bathroom #2 located off the den), bedroom#2, dining room, backyard (outdoor play area) are primary childcare areas. Off-limits areas are :Master bedroom( 1/2 bathroom)., Kitchen, laundry room and front yard.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There is a defunct fireplace in the living room and is made inaccessible as it has a screen around it.

Licensee was informed to purchase a 2A 10BC or 3A Fire Extinguisher as the one located in laundry area does not meet standards established by the State Fire Marshall. Licensee showed LPA Dowling locations of carbon monoxide detector and Smoke detector they were both tested and operable. First Aid kit was complete. There is adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed.

The outdoor play area in the back yard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 197416526
VISIT DATE: 08/26/2025
NARRATIVE
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LPA Dowling observed 1 child in care during today's inspection. Licensee resides in home by herself, she has not additional staff at this time.

LPA Dowling reviewed children’s files and observed files were complete with:

· LIC 700 Identification and Emergency Information


· LIC 627 Consent for Emergency Medical Treatment
· LIC 995A Notification of Parent's Rights
· Immunization Record
· Infant Sleeping Chart for Infant Under 24 Months of Age

LPA Dowling observed following documents posted on bulletin board in living room accessible to parents:

· Facility License


· PUB 394- Notification of Parents Rights
· LIC 9148- Earthquake Preparedness
· LIC 610A- Emergency Disaster Plan

Licensee has Disaster and Fire Drills-last one conducted on 08/18/2025 at 10:46 am to 10:54 am.

Licensee’s was not able to provide verification of Mandated Reporter Training during todays inspection and was informed that this deficiency will result in a Type B citation.

Pediatric CPR/First Aid expires 02/2026

Licensee provides meals and snacks for children in care.

Children have mats to sleep on and infants use play yards. There were 3 play yards observed. Licensee provides bedding for children. The older children have cubbies outside the door to place their personal belongings in. Licensee provides bedding for children in care, if a child has an accident bedding is immediately removed and bedding is changed and washed.

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

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 197416526
VISIT DATE: 08/26/2025
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Isolation area is bedroom#2 if a child is sick in order to keep away from other children in care.

Overnight Care

Licensee does provide overnight care, children sleep in bedroom#2, Licensee uses the simply safe app which she can observe from her cell phone to monitor children overnight. The door to the bedroom is kept open, there are 2 beds in the room and a dresser that each child uses to store their personal belongings.

LPA Dowling observed children in care were in caring and nurturing environment and treated with dignity and respect.

Licensee provided declination of flu shot for herself. Licensee was unable to locate immunization record showing immunization for Pertussis. Licensee will be issued a Type B citation for immunization.

State law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. LPA did not observe any prohibit items in home.

Criminal Record Statement Family Child Care Homes

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA Dowling advised licensee infants must be monitored every 15 minutes when sleeping, their breathing, temperature and color of skin should also be monitored. Licensee is doing the 15 minute sleep observation for the 2 children in care that are under 24 months of age. LPA Dowling observed the Record Observation of Sleeping Infants being documented when children are in care.

Safe Sleep regulation was discussed with licensee as well as the Child Care Licensing Safe Sleep web page listed below that licensee can utilize as an additional resource.

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

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 197416526
VISIT DATE: 08/26/2025
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https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

The licensee is advised to never shake a baby to prevent Shaken Baby Syndrome.

Only children eating may be in high chairs and that car seats are utilized only for transportation. Licensee does not provide transportation to pick up or drop off children in care.

Medication :

LPA Dowling discussed medication with Licensee, currently Licensee does not give medication to children in care. LPA Dowling discussed with Licensee any medication given the medication should be prescribed by child's Doctor and it is to be kept separate with child's name and instructions for giving medication on the label. All medication shall be made inaccessible to children in care.

Incidental Medical Services (IMS) policy

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Exit interview conducted with Licensee. A copy of this report, notice of site inspection, Appeal Rights (LIC 9058), were given and explained

LPA Dowling discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Type B deficiencies were cited during today's inspection (see LIC 809Ds). The Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days

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

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2025 02:31 PM - It Cannot Be Edited


Created By: Dawn Dowling On 08/26/2025 at 01:49 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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 197416526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons, Licensee does not have Mandated Reporter Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Licensee will obtain proof of taking Mandated Reporter training, or will take training and provide LPA Dowling proof of completion by emailing LPA Mandated Reporter Training Certificate.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 person, Licensee does not have proof of immunization against pertussis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Licensee will get blood test from Doctor showing immunized against Pertussis. Licensee will provide LPA Dowling proof of immunization against Pertussis by emailing LPA Doctors letter indicating Licensee is clear from Pertussis.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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