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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493499
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:40:24 PM

Document Has Been Signed on 11/15/2023 04:40 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:KUBI FAMILY CHILD CAREFACILITY NUMBER:
197493499
ADMINISTRATOR:KUBI, LIRANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 625-4840
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Liran Kubi - LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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On 11/15/2023, Licensing Program Analyst (LPA) Suzette Ornelas conducted an unannounced case management inspection for the purpose of deficiencies observed during a complaint investigation for control #58-CC-20231106133811. Upon arrival LPA was greeted by Licensee, Liran Kubi and observed 6 children and 2 adults.

According to the Reporting Party, children's personal rights were violated while in care. LPA Ornelas obtained and reviewed evidence provided in the form of photographs taken of children in high chairs during activities.

Based on the evidence obtained, children were observed in high chairs for a purpose other than eating.
During todays visit, LPA explained to the Licensee that children are only to be placed in high chairs for the purpose of eating meals. Licensee understands and will comply.

The following Type B deficiency is being cited in accordance to Title 22 of the California Code of Regulations:
Personal Rights 102423(a)(4)
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
(4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning. Please refer to 809-D for cited deficiency.

A copy of this report, notice of site visit, and appeal rights were provided. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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 11/15/2023 04:40 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 11/15/2023 at 11:23 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: KUBI FAMILY CHILD CARE
FACILITY NUMBER: 197493499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2023
Section Cited
CCR
102423(a)(4)

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102423(a)(4) Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization... These rights include, but are not limited to, the following:
(4) To be free from corporal or unusual punishment... or other actions of a punitive nature, including, ... aids to physical functioning
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Licensee agrees to understanding the childrens personal rights and will create a decleration and sign it and submit to LPA.
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This requirement is not met as evidence by: children were observed in high chairs for a purpose other than eating.
This is a type B deficiency as it poses a potential risk to the health and safety of children in care.
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During todays visit, Licensee created and signed a Decleration and cleared the deficiency

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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:Betty Bell
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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