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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493795
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:00:52 PM

Document Has Been Signed on 11/05/2021 01:00 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MORRIS FAMILY CHILD CAREFACILITY NUMBER:
197493795
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Wendy BrownTIME COMPLETED:
01:10 PM
NARRATIVE
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On 11/05/2021 at 9:12 AM Licensing Program Analyst (LPA's), Stella Gutierrez and Carolyn Tuba arrived at the facility for the purpose of an inspection. Upon arrival LPA's observed 8 children in care with 1 adult providing supervision and care. Adult providing care is with criminal record clearance, associated to the facility and has CPR/First Aid Certified. During today's inspection LPAs could not be provided records for the children enrolled at the facility. Provider stated that she does not have access to the records by locked door. Licensee, Monet Morris was contacted and a code was provided by Licensee that did not work on locked code door.

Names of children and parent contact numbers were provided to LPA's during todays inspection.

Type B deficiencies will be cited today. A copy of this report and notice of site visit was provided to Wendy brown.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 11/05/2021 01:00 PM - It Cannot Be Edited


Created By: Stella Gutierrez On 11/05/2021 at 12:07 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: MORRIS FAMILY CHILD CARE
FACILITY NUMBER: 197493795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
CCR
102421

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102421 Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d)(1) The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child.
(b)....
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Licensee will provide LPA, Gutierrez a full completed file for all children enrolled at the facility by means of unannounced visit to the facility. This requirement must be met by 11/08/2021 and be readily available for LPA's observation.
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Based on today's inspection this requirement was not met as evidence by observation and file review by LPA's.
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Type B
11/08/2021
Section Cited
CCR102417(g)(8)

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102417
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 be limited to:(8) Each family child care home shall have a current roster of children.....
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Licensee will provide LPA, Gutierrez a copy of this children's roster of all children enrolled at the facility to LPA via email to stella.gutierrez@dss.ca.gov by 11/08/2021 no later than 5:00 PM PST
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Based on todays inspection this requirement was not met by evidence by observation and records review by LPA's.
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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:Karren Starks
LICENSING EVALUATOR NAME:Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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