198012957-5-19-2025-54-CC-FWHE-DGQVV3-20250516164540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198012957
Report Date: 05/16/2025
Date Signed: 05/19/2025 01:53:47 PM

Document Has Been Signed on 05/19/2025 01:53 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 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:	05/16/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Donna Blaylock		TIME VISIT/ INSPECTION COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Franchesca White arrived at the above facility for the purpose of an Annual - Random inspection. LPA White announced the purpose of the visit and was granted entry into the facility by licensee Donna Blaylock. The hours of operation are 24 hours (Monday - Sunday). The ages of the children served in this facility are infant to 13 yrs. There are 15 children enrolled, and 2 children present at inspection. All adults in the home were discussed and have current criminal background clearance. The following Parent Board documents were available during today's inspection: License, Parents' Rights, Emergency Disaster Plan, Emergency Preparedness, The Disaster Drill Log was available during today's inspection and the last drill was conducted 4/1/2025. The Facility Roster was available and is current at the time of inspection. All life saving devices were inspected and found operable at the time of inspection. The dual carbon monoxide / smoke detector is located in bedroom one and the fire extinguisher is located at the front door with a service tag dated 3/25/2025. Licensee states that the isolation space for sick children waiting to be picked up by a parent and/or guardian is in bedroom 1. This is a one-story home which consists of three bedrooms, two bathrooms, kitchen, living room, front yard and backyard (fenced). LPA observed an ADU behind the home with a separate address 822 E. 73rd. Main care is provided in the living room and three bedrooms. Per Licensee, there are no areas off limits. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: At 2:45 p.m., LPA White observed the living room (Main care space) to have cubby space for children's belongings, a large child's table with plenty of chairs for children in care. (Report Continues 1 of 4 Pages)

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Franchesca White
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: BLAYLOCK FAMILY CHILD CARE	FACILITY NUMBER: 198012957
	VISIT DATE: 05/16/2025

NARRATIVE

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LPA observed the main care area to have a mounted tv, cubbies filled with book and activities for the day care children. There are laminate floors throughout the home.

At 3:00 p.m.LPA White observed bedroom 1 to have cribs, cots, and blankets for the day care children. Licensee states that this is the napping room for the day care children. There are posters of numbers, shapes, reading readiness, and positive affirmations. There is a mounted tv, and car seats stored in this space.

At 3:15 p.m., LPA White observed Bathroom 1 to have one sink, one toilet, a shower, hand washing soap, and toilet paper. There were no flooring hazards, or debris on the floor. Cabinets were made inaccessible with the use of a child safety lock. LPA observed cleaning supplies to be stored high in a storage space behind the bathroom door.

At 3:25 p.m. ,LPA White observed bedroom 2 to have office supplies and a desk. There is a crib for a napping child. Academic posters on the wall, and another mounted tv.

At 3:30 p.m., LPA observed a third bedroom that Licensee states is no longer used by day care children. She states that it is her room and it remains locked during operating hours. Licensee was informed to submit an updated facility sketch to the department.

At 3:40 p.m., LPA White observed the backyard spaced that Licensee states is for the play area for day care children. The perimeter of the yard is fenced with a tent to provide shade to day care children. Age appropriate toys are available. There is a fence and locked gate making a portion of the backyard space inaccessible to children and parents. Licensee states that this area remains locked during operating hours. Licensee states that the gate that leads to the front of the home is locked when children are present. There is a green tarp making the area soft for children to play on. Licensee was advised to make repairs to the back steps to ensure a child does not injure themselves on the wood planks.

Per licensee there are no bodies of water on the premises. LPA did not observe any bodies of water. Licensee states that there are no pets. LPA White did not observe any pets. There are no weapons or firearms in the home. LPA White did not observe any weapons or firearms in the home.
.........................................................Report Continues 2 of 4 Pages.........................................................

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Franchesca White
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: BLAYLOCK FAMILY CHILD CARE	FACILITY NUMBER: 198012957
	VISIT DATE: 05/16/2025

NARRATIVE

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At 3:45 pm., LPA White observed the kitchen to have a sitting area for children with chairs. All cabinets were insepcted and found to be free of chemicals and anything possible dangerous to children in care. Some cabinets are made inaccessible by being bolt locked on both sides making it impossible to open. The floors are clean and free of hazards. LPA observed the medications box, and first aid kit to be stored in a cabinet above the refrigerator. The First aid inspected for ample inventory.

At 3:50 p.m. LPA White reviewed staff files, and found all department required files present at the time of inspection. LPA White reviewed the following documents:
Licensee Donna Blaylock - Mandated Reporter Training Certification: 11/3/2024 (expired 3/2026) / CPR-1st Aid: 10/16/2024 (10/2026). Immunization records were available at the time of inspection.
Assistant - Ronnie Blaylock - Mandated Reporter Training Certification: 11/3/2024 (expires:11/2026) / CPR-1St Aid: 10/16/2024 (expires: 10/2026). Immunization records were available at the time of inspection.

At 4:15 p.m., LPA White reviewed the children's files and found them to contain all department required documentation with required parental signatures.

The following were discussed:
All areas used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating (central air and heat).

Licensee Donna Blaylock was reminded that all adults 18 and over, 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 Child Care Center. 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.

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/.
...........................................Report Continues 3 of 4 Pages.................................................................

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Franchesca White
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 05/16/2025

NARRATIVE

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Licensee Donna Blaylock 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, the LICENSEE Donna Blaylock, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on today's inspection consisting of observations, interviews, and record review there will be no deficiencies cited today in accordance with California Title 22 Regulations.

A notice of site visit was given and must remain posted for 30 days. Failure to post will result in a civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Donna Blaylock. PIN 22-05-CCP Page Six

A copy of the report and appeal rights was given to licensee Donna Blaylock.

..........................................Report Ends here 4 of 4 Pages...................................................................

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Franchesca White
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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