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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495042
Report Date: 07/23/2025
Date Signed: 07/23/2025 01:17:22 PM

Document Has Been Signed on 07/23/2025 01:17 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:NIK FAMILY CHILD CAREFACILITY NUMBER:
197495042
ADMINISTRATOR/
DIRECTOR:		BITA NIKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 926-2140
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
07/23/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Leila Raamezani YektaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced 3 year required inspection at the above facility on 07/23/2025 at 8:30 AM. Upon arrival, LPA disclosed the purpose of the inspection and met with Leila Raamezani Yekta Facility Representative (FR), who guided LPA on a tour of the facility. Licensee was not present during the inspection. There were (nine) 9 day-care children (3 infants) present during today’s inspection. Per FR, there are currently (fourteen) 14 children enrolled. Hours of operation are Mon-Fri 6:00 AM - 6:00PM. Licensee arrived at 12:00 PM.

Upon arrival LPA observed 1 adult was supervising 9 children, placing the facility out of ratio.

At 8:50 AM LPA observed an infant sleeping in a car seat with a thick blanket over them in a bedroom with the door closed (photo taken). LPA informed FR infants must be immediately removed from the car seat when they arrive, LPA also informed FR the door must remain open.

At 9:00 AM another assistant arrived, placing the facility back into ratio. At 9:05 AM Licensee’s spouse arrived.

Between 9:10 –9:30 Am 5 more children arrived including one infant, making the capacity 14 and the facility out of ratio. At 9:48 AM another child arrived, making the facility over capacity with 15 children in care. Facility capacity is not in compliance for a large Family Child Care Home.

LPA observed a signed Declaration written by the Licensee on 2/22/2023 stating she understands ratio and capacity.

LPA toured the home inside and outside. This home is a single-story dwelling with two entrances to the home. The first entrance includes access to the main house, which consists of 7 bedrooms, 6 bathrooms, 1


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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042
VISIT DATE: 07/23/2025
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living room, and kitchen with access to the backyard area. The second entrance has an open floor plan and includes access to 1 daycare room, 1 bedroom and 1 bathroom, kitchen, and front yard.

Per Licensee, areas off limits to children and parents include: The main house.

Per Licensee, areas that are accessible to children include: The second entrance to the home which consist of he daycare room, bedroom, bathroom, kitchen, front yard. The bathroom that the children use is located near the front door and was observed to be clean and free of hazards.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following were observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log. Facility has not conducted any drills, per Licensee the Fire Department informed her drills are no longer required. LPA informed Licensee the Fire Department may not require the drill but Licensing requires the drills to be conducted and documented once every 6 months. LPA provided Licensee with a copy of the Fire and Disaster Drill form.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged but was serviced or purchased within the year. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. LPA observed that detergents, cleaning compounds and medication inaccessible to children. Licensee states that there are no poisons stored in the home and understands that
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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
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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 NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042
VISIT DATE: 07/23/2025
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all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the bedroom, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for 4 infants. LPA observed 6 play yards visible in bedroom #1 and in day-care area. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose objects, bumpers, objects hanging, or objects attached to the play yards. Per Licensee wet or soiled sheets are removed and washed. Each infant has their own play yard and bedding. Bedding is washed weekly. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. LPA observed the staff kept closing the bedroom door with an infant inside of the room. LPA explained to Licensee’s spouse and assistants that they cannot close the door with the infants inside, the door can be slightly closed but they should be able to see the infant inside of the room without touching the door. Per Licensee’s spouse there is a camera inside of the bedroom and they use that to monitor the infants. LPA went inside of the bedroom but did not observe a camera, Licensee’s spouse could not show LPA where the camera was located. Licensee states the following sleep supervision plan for infants: Every 15 minutes we open the door and check on them.

Currently, children are using the front yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.



Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months)

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108-

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042
VISIT DATE: 07/23/2025
NARRATIVE
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Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. During file review at 10:10 Am LPA observed an expired CPR/First Aid certificate for FR Leila Raamezani Yekta, with whom was left alone with children in care from 8:00-9:00 am. LPA did not observe a TB clearance or risk assessment for Licensee’s two assistants.

— Pediatric First Aid and CPR expired: 04/2025
— Mandated Reporter AB1207 expires: 08/2026

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a plan for providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm

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 reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. 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


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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 5 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042
VISIT DATE: 07/23/2025
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 the CPSC to be notified of any recalls on their purchased equipment. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.

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&Rs) throughout California.

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The Licensee was made aware they may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

***For TYPE A ----A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Page 5.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 07/23/2025 01:17 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 07/23/2025 at 12:21 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: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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3
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At 8:52 AM Facility Representative removed infant from car seat, placing the facility back in compliance.
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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4
At 11:50 AM LPA observed 1 child leaving, placing the facility back into compliance for capacity.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Tatiana Bickham
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2025 01:17 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 07/23/2025 at 12:21 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: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 15 children were infants which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
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Licensee stated she does not want to un-enroll any infants, LPA informed Licensee then 2 older children must be un-enrolled if she wants to have 4 infants in order to be in ratio. Licensee must un-enroll 2 older children by the date listed above.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Tatiana Bickham
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 07/23/2025 01:17 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 07/23/2025 at 12:21 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: NIK FAMILY CHILD CARE
FACILITY NUMBER: 197495042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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2
3
4
Licensee will write a statement stating she understands infants must be immediately removed from car seats regardless of parents consent.
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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2
3
4
Licensee shall write a statement stating she understands when infants are sleeping the door cannot be closed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Tatiana Bickham
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
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