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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014381
Report Date: 09/08/2023
Date Signed: 09/08/2023 04:09:58 PM

Document Has Been Signed on 09/08/2023 04:09 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SAWAI FAMILY CHILD CAREFACILITY NUMBER:
198014381
ADMINISTRATOR:SAWAI, STACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 494-3870
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Stacey SawaiTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management inspection.. LPA met with Licensee Stacey Sawai who provided information for the visit. The purpose of the visit is to retrieve contact numbers, observed cleared deficiencies (from a previous) and provide guidance for the Unusual Incident Reporting Process. LPA did not provide an LIC 624B form during the last visit.

LPA provided Licensee with an LIC 624B form and instructions on the Incident Reporting Process. Licensee submitted form to LPA during the visit.

LPA observed the following items cleared:
1. Incident Report submitted
2. Parents Rights placed in children's file.

Open

1. 15 minute checks still in process due to Licensee using white eraser board. LPA explained to place checks on the form provided so that the facility can keep for at least 3 years.
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The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. This report along with a copy of the appeal rights was provided. Exit interview was conducted with Licensee Sawai.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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