198012957-6-11-2026-54-CC-AMOY-DRKPF6-20260223101614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198012957
Report Date: 02/23/2026
Date Signed: 06/11/2026 11:38:57 AM

Document Has Been Signed on 06/11/2026 11:38 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	BLAYLOCK FAMILY CHILD CARE		FACILITY NUMBER:	198012957
ADMINISTRATOR/ DIRECTOR:	BLAYLOCK, DONNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 583-8551
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90001
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	02/23/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Donna Blaylock, Licensee		TIME VISIT/ INSPECTION COMPLETED:	10:45 AM

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*THIS IS AN AMENDED REPORT* On 2/23/26 Licensing Program Analyst (LPA) Alicia Mooberry conducted an Unannounced Case Management Inspection for the purpose of obtaining the licensee's signature on an amended report dated 2/6/26 and issuing a civil penalty for a deficiency cited on the same date.

LPA met with Donna Blaylock, Licensee and was granted entry into the facility. There were 2 children present and Adult 1. All adults present have obtained required background clearances.

An immediate civil penalty was assessed on 2/6/26 for violation of CCR 102423(a). See LIC 421IM. A Non-Compliance Conference will be scheduled with Licensee. A civil penalty is pending determination per H&S Code Section 1596.99(f).

A deficiency is being cited in relation to the investigation concluded and reviewed with licensee on 2/6/26 for violation of HSC 1596.8897(a)(2). Licensee allowed uncleared adult, A1 access to the daycare home which resulted in C1 being touched inappropriately.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt. Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Donna Blaylock, appeal right were discussed and copy provided.

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Franchesca White
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026

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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Document Has Been Signed on 02/23/2026 10:16 AM - It Cannot Be Edited

Created By: Alicia Mooberry On 02/23/2026 at 09:45 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: BLAYLOCK FAMILY CHILD CARE	FACILITY NUMBER: 198012957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2026 Section Cited HSC 1596.8897(a)(2)	1 2 3 4 5 6 7	The department may prohibit any person from being a... licensee...or allowing contact with clients of a licensed facility by...person who is not a client who has: Engaged in conduct that is inimical to the health... safety of either an individual in or receiving services from the facility...	1 2 3 4 5 6 7	Licensee will immediately refrain from allowing A1 to be present at the facility.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Per CCL IB investigation Licensee did not ensure children’s safety by allowing A1 to access the daycare area, resulting in C1 being touched inappropriately. This poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Warren Birks
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Mooberry
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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