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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:13:12 PM

Document Has Been Signed on 11/07/2024 03:13 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:NICHOLAS FAMILY CHILD CAREFACILITY NUMBER:
198017228
ADMINISTRATOR/
DIRECTOR:		NICHOLAS, SHAMEKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 788-0855
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Licensee- Shameka Nicholas TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On November 7, 2024 at 12:00p.m., Licensing Program Analyst (LPA) Keneisha Dunlap arrived at the above facility for the purpose of an unannounced Annual Inspection. LPA Dunlap announced the purpose of the visit and was granted entry into the facility by Assistant. Licensee Shameka Nicholas arrived 15 minutes later. There are 20 children enrolled, and 7 children present at the time of inspection. The hours of operation are Monday- Sunday 12:00a.m.-11:00pm. All adults in the home were discussed and background and fingerprinted cleared. License, Facility sketch, disaster plan, earthquake preparedness checklist, and PUB 394 posted. Licensee does have current LIC 9040 (facility roster). Licensee does not have a current disaster log drill. This poses an potential risk to the health and safety of children in care. A Technical Violation will be issued.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen/dining room, living room, garage, laundry area, front yard and backyard. The off limit areas include 3 bedrooms, one bathroom, laundry area, and garage.



The main care is the living room. There are age appropriate tables and chairs and toys for children. 3 playpens for infants, and 2 high chairs. a mounted TV. There is are cubbies with arts supplies and extra toys. The cots are stored in the main care area in the corner. The Licensee does provide breakfast, lunch, and snack for the children. LPA observed main care area to be in good condition, free of sharp, loose or pointed parts.

LPA observed kitchen with all items inaccessible to children, and laundry area with all items inaccessible to children. LPA observed kitchen area with baby gate making it in accessible to children. All knives stored in high cabinet making it in accessible to children. All cabinets had safety locks making all items inaccessible to children.
The backyard area has age appropriate picnic tables, bikes, toys, and climbing structure. LPA observed the outdoor play equipment to be in good condition, free of sharp, loose or pointed parts. Page 1 of 5
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 11/07/2024
NARRATIVE
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There are 5 dogs on the premises.

LPA observed the smoke detector and carbon monoxide detector to be operable.

LPA observed a fire extinguisher with an expiration date of 10/21/24.

Staff Files:

Staff # 1

Have required immunization records in folders.

Files is missing LIC 9108, 9052,

CPR expiration date of 6/7/25

Mandated Reporter expiration date of 1/11/26

Staff # 2

File is missing immunization records, TB test and CPR & First Aid .

Files is missing LIC 9108, 9052

Mandated Reporter expiration date of 11/22/26

Staff # 2 Missing immunization and TB test- This poses an potential risk to the health and safety of children in care. A Type B will be issued.

Staff # 3

Have required immunization records in folders.

Files is missing LIC 9108, 9052,

CPR expiration date of 6/7/25-

Mandated Reporter expiration date of 11/12/26

All Staff missing LIC 9052- This poses an potential risk to the health and safety of children in care. A Technical Violation will be issued. Page 2 of 5

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 11/07/2024
NARRATIVE
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Children Files:

Child #1


All required immunization records and licensing forms are in file with the exception of the LIC 9227 and safe sleep logs

Child #2

All required licensing forms are in file. File is missing immunization record.

Child #3

All required immunization records and licensing forms are in file with the exception of the LIC 9227 and safe sleep logs

Child 1 & 3 missing Missing LIC 9227 and safe sleep logs & Child 2 missing immunization record - This poses an potential risk to the health and safety of children in care. 2 Type B's will be issued.

The Licensee stated that they communicate with parents via phone, person, parent board, and/or newsletters

The Licensee has a cell phone and landline that they use.



The Licensee stated they do not have any children that they administer medication to at this time.

The Licensee states that when children are in sick, they are placed in the main care area by the door.

The Licensee stated there are no firearms in the home.

The Licensee stated that there are no smokers in the home.

The Licensee stated that they do provide transportation for children.
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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 11/07/2024
NARRATIVE
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The Licensee stated they do not have any children with allergies.

The Licensee stated that they do have first aid kit.

There are no large bodies of water on the premises.

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

Criminal Record Clearance - Family Child Care Homes Licensee Shameka Nicholas 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.

Safe Sleep

LPA discussed the safe sleep regulations with Licensee Shameka Nicholas and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Licensee Shameka Nicholas of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
VISIT DATE: 11/07/2024
NARRATIVE
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MyChildCarePlan.org – Centers and Family Child Care Homes Licensee Shameka Nicholas 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.

Megan’s Law - Family Child Care Homes During the exit interview, the Licensee Shameka Nicholas, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Appeal rights explained and given to Licensee Shameka Nicholas

4 Type B will be issued during todays inspection.

2 Technical Violations will be issued during todays inspection.

Exit interview conducted and report was reviewed with the Licensee Shameka Nicholas

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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 03:13 PM - It Cannot Be Edited


Created By: Keneisha Dunlap On 11/07/2024 at 02:03 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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 3 children files were missing logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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The Licnesee will keep current logs in a folder for recrod review.
The Licensee will log every 15 minutes children sleeping while in care.
The Licensee shall submit logs to LPA via email by POC date.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out 3 staff files did not have current CPR & First Aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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The Licensee will have staff either take class or obtain CPR card by POC date.
The Licensee will keep a copy of certificate in staff file.
The Licensee will send copy of certificate to LPA via email by POC date.
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:Karen Chambers
LICENSING EVALUATOR NAME:Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/07/2024 03:13 PM - It Cannot Be Edited


Created By: Keneisha Dunlap On 11/07/2024 at 02:03 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: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out 3 children files did not have immunization record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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The Licensee will obtain copy of immunization record from parent.
The Licensee will keep copy in childrens file.
The Licensee will email LPA a copy of immuinzation by POC date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 3 children files did not have LIC 9227 form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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The Licensee will have all parents fill out forms
The Licensee will place copies in children files.
The Licensee will email LPA copies on or before POC date.
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:Karen Chambers
LICENSING EVALUATOR NAME:Keneisha Dunlap
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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