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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494046
Report Date: 08/14/2025
Date Signed: 08/26/2025 10:26:59 AM

Document Has Been Signed on 08/26/2025 10:26 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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CHAMBERLAIN FAMILY CHILD CAREFACILITY NUMBER:
197494046
ADMINISTRATOR/
DIRECTOR:		KRISTIN CHAMBERLAINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(808) 346-0982
CITY:LOS ANGELESSTATE: CAZIP CODE:
90230
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
08/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:58 AM
MET WITH:Adriana Bastos, AssistantTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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On 8/14/2025, Licensing Program Analyst (LPA) Ranita Richmond and Brittany Lovest conducted an unannounced Random/ Annual visit to the above-named home. LPA rang the ring camera doorbell and called telephone number on file for licensee and left a voice message. Licensee returned LPA’s call and after a total of approximately 20 minutes LPAs were greeted by assistant Adriana Bastos. Licensee was not in the home during the visit. Type B citation cited. See LIC 809D. Per assistant, licensee has been out of the home for the entire week. Per licensee her anticipated arrival is on 8/15/25 in the PM. LPA observed 12 children, being supervised and cared for by three finger print cleared staff. Hours of operation are Monday through Friday, 8:00am –5:00pm. Licensee is not open for overnight and weekend care. Licensee provides lunch and water.

LPA toured the home inside and outside for a Health and Safety inspection.

LPA Richmond confirmed that the home is a single story home. The home consists of three bedrooms, two bathrooms, living room, kitchen, dining room, attached garage, additional dwelling unit located in the back yard, and fenced back yard.

The ON LIMIT AREAS are as follows: Bedroom #2 & #3, bathroom #2, additional dwelling unit, and fenced back yard.

The OFF-LIMIT AREAS are as follows: kitchen, bedroom # 1, bathroom #1, and living room, dining room, and attached garage.

Children and parents enter the FCC through the side gate to the right of the house. They then make two left turns to be located in front of sliding patio doors of bedroom #3. Inside bedroom #3 is bathroom #2. While standing in bedroom #3 to the right is bedroom #2. Inside bedroom #2 is a door that leads to the hallway where bedroom #1 to the right and bathroom #1 to the left. The hallway has an entry way that leads to kitchen on the left and dining room, straight ahead, and living room to the right. Inside the kitchen is a door that leads to the outside, side of the house. Inside the living room is a door that leads to the outside front of the house. When entering the home from the side of the house if you make a left and then a right turn you are located in front of the additional dwelling unit in the back yard.
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NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046
VISIT DATE: 08/14/2025
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Licensee is aware that the children must nap, toilet, and have meals in the home.

LPA observed a fully charged 2A:10B:C Fire Extinguisher in the hallway closet and one in the additional dwelling unit. The smoke detector is located on a wired pull system throughout the home. The last inspection for fire system was completed in February 2024. The home has a smoke detector/carbon monoxide dual located in bedroom #3.

There is a screened fireplace in the living room and an open face heater without proper barricade in the living room. Type B citation cited. See LI 809D.

There are no firearms or ammunition on the premises. There are no pools, ponds or other bodies of water on the premises.

LPA Richmond observed age-appropriate toys, books and furnishings. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts.

During walkthrough LPA observed six children wearing sleep sacks. Type A citation cited. See LIC 809D. LPA advised assistants to remove children from sleep sacks due to sleep sacks being prohibited due to swaddling. LPA observed medications on the kitchen counter and inside bathroom #2 medicine cabinet accessible to children in care. Type B citation cited. See LIC 809D. LPA reviewed facility forms and observed last fire drill completed 1/19/24. Type B citation cited. See LIC 809D.

LPA reviewed 12 children’s files and observed four of twelve files to contain missing signatures for current contact information for authorized representatives and/or relatives who can assume responsibility for the child. Type B citation cited. See LIC809D. LPA reviewed infant file C10 and observed LIC 9227 to be missing provider signature. Type B citation cited. See LIC 809D.

LPA observed S10 asleep on a cot laying on their stomach. Type B citation cited. See LIC 809D. LPA reviewed Bright Wheel App for sleep logs. LPA observed sleep logs are not input into the app every 15 minutes as infant children are asleep. Type B citation cited. See LIC 809D.

LPA reviewed the facility roster and observed ten of twelve children in care are not listed on facility roster. Type B citation cited. See LIC 809D.

LPA Richmond reviewed staff files and observed three of four files to be missing current flu vaccination information. Type B citation cited. See LIC 809D.

Licensee has a cat that is housed in the off limits areas in bedroom #1 during daycare hours.

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NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046
VISIT DATE: 08/14/2025
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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. During file review LPA observed missing infant sleep charts. Type B citation cited. LPA provided licensee with infant sleep charts for daily completion.

Incidental Medical Services (IMS) are not currently being provided.



Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA Richmond reminded Licensee of 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.

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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&R) throughout California.

LPA Ranita Richmond informed assistant Adriana Bastos that this report dated 8/14/25 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Ranita Richmond informed the licensee to provide a copy of this licensing report dated 8/14/25 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046
VISIT DATE: 08/14/2025
NARRATIVE
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Ten (10) Type B Deficiencies were cited today, per Title 22 Regulations and Health and Safety Codes. See LIC 809D.
An exit interview was completed with licensee Assistant Adiana Bastos. A copy of report and appeal rights were provided to licensee.
Notice of Site Visit provided and required to be posted for 30 days.

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NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 04:30 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(d)(3)A

(d)The provider shall place infants up to 12 months of age on ther backs for sleeping. (3)An infant with an Individual Infant Sleeping pLan (LIC 9227) that has Section C of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep...A. Upon the providers observation that the infant is capable of rolling from their back to their stomach and stomach to their Back, the provider shall fill out Section D....
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not positioning infant C10 on their back to sleep which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Staff will sign Section D of LIC 9227 immediately after observing C10 ability to roll from stomach to back and back to stomach. Staff will email LPA copy of completed form for file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 12 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(f)
Infant Safe Sleep
An infant shall not be swaddled while in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above six of twelve children were swaddled in sleep sacks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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2
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Immediately remove sleep sacks from FCC as sleep sacks are prohibited due to being a swaddling device.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above open face heater in living room without protective barricade which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will contact gas company to provide documentation that the gas line has been removed from open face heater.
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above medications accessible to children in care on the kitchen counter and bathroom #2 medicine cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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2
3
4
Medications will be immediately relocated to a locked and or off limits area.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above last documented fire drill completed January 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Licensee will conduct a fire drill with FCC and submit documentation 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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above licensee was out of town away from the home for a weeks time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Licensee will communicate with the Department any instances that occur that will have licensee temporarily absent from the home that exceed 20 percent of the hours that the facility is providing care.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above staff did not document infants sleep on infant sleep chart which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Staff will document infants sleep every 15 minutes as infants sleep in the FCC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above three of four staff files are missing flu vaccine information/documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Staff will take flu vaccine or complete flu declination for file.
Type B
Section Cited
CCR
102421(a)(1)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility roster does not reflect currently enrolled or date left of children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Licensee will update facility roster to reflect currently enrolled children and date left of children not currently enrolled.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 08/26/2025 10:26 AM - It Cannot Be Edited


Created By: Ranita Richmond On 08/14/2025 at 05:12 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: CHAMBERLAIN FAMILY CHILD CARE
FACILITY NUMBER: 197494046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above children's files are missing signatures for LIC 700 forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Staff will provide forms to parents for signature for file as early as next day child is in care.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above roster does not reflect currently enrolled children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
1
2
3
4
Licensee will update facility roster 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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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