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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008375
Report Date: 12/21/2021
Date Signed: 12/21/2021 11:02:42 AM

Document Has Been Signed on 12/21/2021 11:02 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MERRIMAN FAMILY CHILD CAREFACILITY NUMBER:
198008375
ADMINISTRATOR:MERRIMAN, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 864-5534
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 6DATE:
12/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Jacqueline MerrimanTIME COMPLETED:
11:23 AM
NARRATIVE
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Licensing Program Analyst (LPA) R. Navarro conducted a Case Management Deficiencies Inspection to address citation observed. There were six children present in the facility at the time of inspection. LPA met with Licensee Jacqueline Merriman who guided LPA on indoor and outdoor tour of the facility.

During an inspection, LPA determined during file review that there were two assistants who were not fingerprint cleared and associated at the facility during the time of inspection. Licensee also did not have a current children's roster. A civil penalty of 200 dollars was assessed during today's inspection.

See deficiencies page for deficiencies cited during today's inspection.

Exit interview conducted with Licensee Jacqueline Merriman. Appeal rights explained and provided.

LPA Navarro informed licensee Jacqueline Merrimam that this report dated 12/21/21 documents Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Navarro informed the licensee to provide a copy of this licensing report dated 12/21/21 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.

"Notice of Site Visit" and report was issued. Notice of Site Visit must remain posted for 30 days. Failure to do so will result in a $100.00 civil penalty.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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 12/21/2021 11:02 AM - It Cannot Be Edited


Created By: Raul Navarro On 12/21/2021 at 10:26 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MERRIMAN FAMILY CHILD CARE
FACILITY NUMBER: 198008375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
CCR
102370(a)

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Criminal Record Clearance- (a) Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. This requirement was not met as evidenced by LPA's observations and file review.
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Licensee will have their son and daughter fingerprinted immediately. Licensee will submit proof of fingerprint clearance by the POC date of 10/22/21.
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 Licensee's son and daughter were present in the facility and have not obtained fingerprint clearance. This is an immediate risk to the health and safety of the children in care. A civil penalty of $200.00 was assessed during today's inspection.
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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:Karen Chambers
LICENSING EVALUATOR NAME:Raul Navarro
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2021 11:02 AM - It Cannot Be Edited


Created By: Raul Navarro On 12/21/2021 at 10:31 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MERRIMAN FAMILY CHILD CARE
FACILITY NUMBER: 198008375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited
CCR
102417(g)(8)

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Operation of a Family Child Care Home. Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. . This requirement was not met as evidenced by LPA's observations and file review.
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Licensee will complete a current roster and submit a copy to LPA by the POC date of 01/03/21.
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Licensee did not have a current roster available during the inspection. This is a potential risk to the health and safety of the children in care.
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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:Karen Chambers
LICENSING EVALUATOR NAME:Raul Navarro
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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