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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400770
Report Date: 07/10/2025
Date Signed: 07/10/2025 12:04:31 PM

Document Has Been Signed on 07/10/2025 12:04 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:LEWIS FAMILY CHILD CAREFACILITY NUMBER:
198400770
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Christy Cottman, AssistantTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Dayna Chambers and Ashley Calderon conducted an unannounced case management inspection for the purpose of citing deficiencies from previous inspection on 06/30/25. These citations were not generated due to computer issues. Upon Arrival, licensee was not present due to transporting children. LPAs met with Christy Cottman, Assistant. LPAs observed 4 children upon arrival. Assistant provided a tour of the facility. LPAs observed that Brisa Nunez, assistant arrived at the home at 10:11am with her child. There are currently 5 children in care at 10:20am. Per Licensee, operation hours are Monday through Friday: 2:00am to 11:59PM, Saturdays: 8:30am to 4:30pm, and closed on Sundays. Licensee cares for children 0 to 12 years of age. LPAs reviewed current roster and there are currently 14 children enrolled.
On 06/30/25, LPA Chambers observed 4 infants and 3 children in care. , LPA documented children in care on LIC811. In addition, there were no school age children. A type A citation is being cited today regarding Title 22, Division 12, Chapter 3, Article 06. Continuing Requirements 102416.5(b)(2) Staffing Ratio and Capacity are being cited on the attached LIC 9099D. LPA provided a capacity sheet for the licensee and requested TSP training.
On 06/30/2025, LPA Chambers conducted a capacity increase /annual random inspection. Due to network issues with FAS, LPA was unable to cite the licensee for the following observations: LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed a child #1 under the age of 6 years old, jumping on the trampoline. LPA verified child’s age through review of files and roster. Trampoline details: Skywalker Trampoline -12 feet round with enclosure. LPA checked the age range for the trampoline, and it is intended for kids aged 6 years and up. LPA observed that adult staff #2 was providing supervision. LPA advised the licensee that children under the age of 6 years old were not permitted to use the trampoline. LPA advised licensee to lock the netting zipper and snap around the trampoline. LPA advised
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Dayna Chambers
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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: LEWIS FAMILY CHILD CARE
FACILITY NUMBER: 198400770
VISIT DATE: 07/10/2025
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licensee to remove the ladder and make it inaccessible to all children. License corrected the deficiency during the inspection on 06/30/2025.

On 06/30/2025, LPA Chambers observed an adult #2 supervising children in the daycare. LPA reviewed staff records and observed that Adult #2 was missing immunization records for MMR and TDAP. Licensee has corrected this deficiency by submitting the immunization record to LPA on 07/09/25.

A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility. 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 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.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility.
Exit interview conducted and a copy was given to the Licensee Keahna Lewis.
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Dayna Chambers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/10/2025 12:04 PM - It Cannot Be Edited


Created By: Dayna Chambers On 07/10/2025 at 10:56 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: LEWIS FAMILY CHILD CARE
FACILITY NUMBER: 198400770

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2025
Section Cited
CCR
102416(b)(2)

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102416(b)(2) Staffing Ratio / Capacity Six Children, no more than three of whom may be infants: This requirement is not met as evidenced by... On 06/30/25,small fcch, LPA Chambers observed 4 infants and 3 children, no school age, in care for a total of 7 children.
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Licensee was not present during inspection. Licensee will submit to LPA each child enrolled on the roster with their schedules, drop off and pick up times. 7/21/2025.
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Which poses an immediate Health, Safety, or Personal Rights Risk to children in care.
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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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Dayna Chambers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2025 12:04 PM - It Cannot Be Edited


Created By: Dayna Chambers On 07/10/2025 at 11:10 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: LEWIS FAMILY CHILD CARE
FACILITY NUMBER: 198400770

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2025
Section Cited
CCR
102423(a)(2)

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Personal Rights To receive safe, healthful, and comfortable accommodations, furnishings, and equipment... This requirement is not met as evidenced by...On 06/30/2025, . LPA observed a child #1 under the age of 6 years old, jumping on the trampoline. LPA observed child #1 jumping
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Licensee corrected the defiency on 06/30/25 while LPA was present. Licensee removed the ladder and zipped up the enclosure. Licensee will not let the children use the trampoline for children under 6 years of age.
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on a trampoline intended for age 6 years and up. Skywalker Tranpoline 12 feet round with enclosure. Child #1's age was verified through review of children's file which poses/posed a potential Health, Safety, or Personal Rights Risk to children in care.
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Type B
07/10/2025
Section Cited
HSC1597.622(a)(1)

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Health / Safety 1597.622(a)(1)Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by On 06/30/25, LPA reviewed staff files and the immunization record was missing.


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Licensee's staff, adult #2 completed the antibody test for MMR on 07/03/25. The record will be placed in staff file.
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which poses/posed a potential Health, Safety, or Personal Rights Risk to children in care.
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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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Dayna Chambers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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