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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416987
Report Date: 10/08/2025
Date Signed: 10/08/2025 10:44:02 AM

Document Has Been Signed on 10/08/2025 10:44 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THEFACILITY NUMBER:
197416987
ADMINISTRATOR/
DIRECTOR:		BACH, ROCIOFACILITY TYPE:
850
ADDRESS:15711 SOUTH ATLANTIC AVE.TELEPHONE:
(310) 637-1593
CITY:E. RANCHO DOMINGUEZSTATE: CAZIP CODE:
90221
CAPACITY: 42TOTAL ENROLLED CHILDREN: 42CENSUS: 7DATE:
10/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Site Supervisor NatashaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 10/8/25 Licensing Program Analyst (LPAs) Tyler Reyes conducted an unannounced Case Management-Incident inspection to follow up on incident that was reported to the Department 9/22/25. LPA met with Site Supervisor Natasha who guided LPA on a tour of the classroom. LPA observed (7) children in care and (7) children listed present on Attendance Record 10/8/25. LPA observed (3) teachers and (1) aid. The following individuals were present were Staff 1(S1-S4).

Adults present have obtained criminal record clearance or exemption. LPA informed that any individual that has direct contact with the children is required to have a criminal record clearance or exemption.

On 9/22/25, an unusual incident report (UIR) was made to the Department regarding an incident that occurred on 8/25/25. Per UIR, parent 1 (P1) of child 1 (C1) reported to staff 1 (S1) that a substitute teacher held her child’s head down forcefully on the cot during nap time. C1 stated the action caused pain. No visible bruises were observed by staff.

Site Supervisor reported the incident to the substitute staffing agency and substitute teacher was removed from classroom. Per Site Supervisor Natasha C1’s parents were satisfied with correct action.

On 10/8/2025 LPA spoke with P1 regarding the incident that occurred on 8/25/25. P1 stated that there were no further concerns and confirmed no medical treatment was received for C1. Per interview with Site Supervisor Natasha C1 did not receive any medical attention related to the incident. Site Supervisor Natasha states no prior concerns or similar incidents reported. Per Site Supervisor personal rights of children were reviewed with staff and substitute staffing agency. LPA obtained the Daily Attendance Record for 8/25/25 which indicated (7) children were present including C1. Based on information provided by Site Supervisor Natasha LPA observed S1 and S2 present on 8/25/25.

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THE
FACILITY NUMBER: 197416987
VISIT DATE: 10/08/2025
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LPA discussed with with Site Supervisor Natasha regarding submitting UNUSUAL INCIDENT/INJURY REPORT LIC 624 to the incident mailbox.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days consecutive days . Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview conducted and a copy of the report and appeal rights were provided to Site Supervisor Natasha. No deficiencies cited.
NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
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