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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494546
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:03:29 PM

Document Has Been Signed on 02/23/2022 03:03 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:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
197494546
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
02/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Karin DavisTIME COMPLETED:
03:15 PM
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On 02/23/2022 Licensing Program Analyst (LPA) Laticia Thompson conducted unannounced case management visit to inspect body of water. LPA observed 5 children 2 adults. LPA was unable to verify Criminal Record Clearance for second adult in home.

LPA observed backyard area and determined there were not any visual bodies of water. Per review of prelicensing report there is a mention of a children pool. LPA reiterated instruction regarding child pool and provided licensee with hand outs and regulations regarding bodies of water.

Licensee stated second Adult in home is her mother, Gloria Davis. Licensee stated adult has a criminal clearance background check but was unable to provide documentation. LPA will confirm information upon return to office. Per guardian printout second adult does not appear on Facility roster. There are no deficiencies issued at this time. Criminal background clearance pending verification. LPA advised licensee to log on to guardian and updated information or submit the following documents to the Regional Office by 02/25/2022:

1) Criminal Record Statement (LIC 508)
2) Valid Photo Identification
3) TB/Tuberculosis Test (taken within the last year)
4) LIC 9108 STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT CHILD ABUSE
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Laticia S Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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