<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012005
Report Date: 09/03/2026
Date Signed: 09/03/2026 01:55:19 PM

Document Has Been Signed on 09/03/2026 01:55 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:BUTLER-ELDER FAMILY CHILD CAREFACILITY NUMBER:
198012005
ADMINISTRATOR/
DIRECTOR:		BUTLER-ELDER, SHIRLETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 296-0133
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
09/03/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Licensee, Shirlette Butler-ElderTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 3, 2026 at 12:15 pm Licensing Program Analysts (LPA) Priscilla Ochoa conducted an unannounced annual inspection at the above facility. LPA was greeted by Licensee, Shirlette Butler-Elder who guided LPA on a tour of the facility. Per licensee there are 3 children enrolled, and LPA observed 1 infant and 2 preschool aged children in care. Hours of operation are Monday - Friday from 6:30 am – 6:00 pm.

Family members residing in the home are 2 adults who obtains criminal record clearance. This is a two-story home that consists of 3 bedrooms, 2 bathrooms, living room, dining area, kitchen, side yard, backyard (fenced), back house and detached garage.

Off limit areas for children and parents is the entire second floor that include 1 bathroom and 2 bedrooms, living room, backyard, back house and detached garage.

Areas accessible to children in care are 1 bedroom downstairs, 1 bathroom in down stairs bedroom, dining area and side yard.

At 12:25 pm licensee guided LPA on a tour of the facility. Per licensee, parents enter through the front door of the home which leads them to the dining area, where LPA observed a couch and dining table and chairs. LPA was then guided to bedroom 1 where LPA observed 3 napping children on cots. Per licensee all bedding is washed at the facility weekly. In bedroom 1 LPA observed age-appropriate toys for children in care. The bathroom in bedroom 1 was then inspected and was clean and orderly. LPA observed a child safety gate between the living room and dining area preventing children from having access to the living room area. The side yard was then inspected and observed age-appropriate toys and outdoor equipment for children in care.

Page 1 of 3

Ana Chico
Priscilla Ochoa
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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 7
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)
Page: 2 of 7
Document Has Been Signed on 09/03/2026 01:55 PM - It Cannot Be Edited


Created By: Priscilla Ochoa On 09/03/2026 at 01:07 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BUTLER-ELDER FAMILY CHILD CARE
FACILITY NUMBER: 198012005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026

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, interview, record review, the licensee did not comply with the section cited above in licensee did not obtain the correct fire extinguishe to be in compliance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
1
2
3
4
Licensee will purchase a 2A:10-B:C fire extinguisher. Licensee will show proof to LPA by POC date of 09/11/26
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 in 1 out of 3 children were missing 15 minute safe sleep log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
1
2
3
4
Licensee will document safe sleep every 15 minutes and note labor of breathing, position of the child while they are napping, (stomach, back or side) and other observations. Licensee will send LPA proof of 15-minute safe sleep log documentation by POC date of 09/11/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/03/2026 01:55 PM - It Cannot Be Edited


Created By: Priscilla Ochoa On 09/03/2026 at 01:07 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BUTLER-ELDER FAMILY CHILD CARE
FACILITY NUMBER: 198012005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 in 3 out of 3 children were missing LIC 995A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure parents of C1 - C3 comeplete and submit LIC 995A. Licensee will provide proof to LPA by POC date 9/08/26

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/03/2026 01:55 PM - It Cannot Be Edited


Created By: Priscilla Ochoa On 09/03/2026 at 01:07 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BUTLER-ELDER FAMILY CHILD CARE
FACILITY NUMBER: 198012005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 in 1 out of 3 children were missing LIC 282, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure the parent of C3 complete and submits LIC 282. Licensee will send proof to LPA By POC date of 09/08/26
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.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BUTLER-ELDER FAMILY CHILD CARE
FACILITY NUMBER: 198012005
VISIT DATE: 09/03/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All areas were observed to be clean, orderly, comfortable, and well ventilated. LPA also observed the back yard which is currently inaccessible to children in care as the facility is using it as storage. LPA observed the back yard to be locked ensuring it is inaccessible.

There are first aid supplies available. Per licensee, the facility provides all meals for children in care. LPA reminded the licensee that food brought from home must be labeled with the child’s name, stored properly and or refrigerated.

If a child becomes ill, the child is isolated in the living room while the parents are called. A cot is available if needed.

Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children.

LPA observed a smoke/carbon monoxide detector in the dining room. However, LPA did not test detectors as children were napping. LPA observed a 1A-10BC fire extinguisher in the living room area. The valve on the fire extinguisher pointed to the fully charged green section. LPA reminded licensee to be in compliance they are required to have a 2A:10-B:C fire extinguisher and the licensee would not locate receipt to show LPA when it was purchased. LPA reminded licensee, receipts should be saved and kept handy for inspection. There is a working telephone on site. Per Title 22 Emergency Disaster Drill must be conducted and documented at least every 6 months. LPA observed the last disaster drill to be conducted and documented on 8/20/2026.

Per the licensee, there are no weapons, pets or bodies of water on the premises. Licensee obtains a current Pediatric First Aid and CPR certification which expires on 04/25/2028.

LPA did conduct a children file review and deemed it not complete. 1 out of 3 children were missing LIC 282, 3 out of 3 children were missing LIC 995A, and 1 out of 3 children were missing 15 minute safe sleep logs in their file for LPA to review. LPA consulted with licensee about safe sleep and provide a licensee a sample sleep chart to use to document every 15 minutes.

LPA conducted staff file review and deemed it complete.

Licensee has completed mandated reporter training which expires 01/11/2027. All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years at www.mandatedreporterca.com

Page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BUTLER-ELDER FAMILY CHILD CARE
FACILITY NUMBER: 198012005
VISIT DATE: 09/03/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) and Earthquake preparedness Checklist.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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 Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on the LPA’s observations and record 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 and safety.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee, Shirlette Butler-Elder.

Page 3 of 3

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7