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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012957
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:57:57 PM

Document Has Been Signed on 10/10/2024 02:57 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 CAREFACILITY NUMBER:
198012957
ADMINISTRATOR/
DIRECTOR:		BLAYLOCK, DONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 583-8551
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 14TOTAL ENROLLED CHILDREN: 25CENSUS: 3DATE:
10/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Donna BlaylockTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analyst (LPA), T. Tran observed the following deficiencies:

During file reviewed, LPA observed C1 & C3 missing immunization records and no record of infant safe sleep chart for C1. Licensee and employee did not current CPR and First aid certification.

Facility was cited a type B deficiencies. See Facility Evaluation Report LIC 809D for deficiency cited.

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


Exit interview conducted and report was reviewed with the facility representative, Donna Blaylock.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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 10/10/2024 02:57 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 10/10/2024 at 02:35 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: BLAYLOCK FAMILY CHILD CARE
FACILITY NUMBER: 198012957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
102425(j)(1)

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Infant Safe Sleep
This requirement is not met as evidenced by
based on record review facility failed to have safe sleep chart for C1 which poses a potential health and safety risk to children in care.
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Licensee agrees to complete the safe sleep chart for C1 then submit to LPA by or before 10/31/24 in order to clear this citation
Type B
10/10/2024
Section Cited
CCR
102418

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Immunizations
This requirement is not met as evidenced by
based on record review facility failed to obtain immunization for C1 & C3 which poses a potential health and safety risk to children in care.
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Licensee agrees to request the immunization records from C1 & C3 from the parents then submit to LPA on or before 10/31/24 in order to clear this citation.
Type B
10/31/2024
Section Cited
CCR102416(1)(1)

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Personnel Requirements
This requirement is not met as evidenced by
based on record review licensee and employee failed to obtain current CPR & First Aid certificate which poses a potential health and safety risk to children in care.
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Licensee agrees to have her and employee complete the CPR and First Aid training then submit to LPA on or before 10/31/24 in order to clear this citation.

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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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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