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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400807
Report Date: 04/17/2025
Date Signed: 04/17/2025 01:05:04 PM

Document Has Been Signed on 04/17/2025 01:05 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:CLARK FAMILY CHILD CAREFACILITY NUMBER:
198400807
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
04/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:16 AM
MET WITH:Licensee, Shakeena ClarkTIME VISIT/
INSPECTION COMPLETED:
01:16 PM
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On 04/17/2025 at 08:16 am, Licensing Program Analyst (LPA) Jonnisha Culbert performed an unannounced case management inspection at the facility noted above. LPA met with licensee, Shakeena Clark stated the purpose of today’s visit is to inspect the home for a Large Family Childcare license. Licensee currently has a license for a capacity of 8 and wishes to increase capacity to 14. Fire inspection for the increase was completed and approved on 03/27/2025. LPA provided licensee with an Entrance Checklist for Family Child Care Homes (LIC 126). Present at the time of inspection were Licensee, assistant, and 8 children. Licensee guided LPA on a tour of the facility. Individuals residing in the home were discussed and noted. Per licensee, the operating hours are Monday through Friday from 7am to 5:30pm.

This is a single-family home that consists of Three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, detached converted garage, fenced backyard, driveway, and front yard.

Areas that are accessible to children include: One (1) bathroom, living room, dining area, kitchen, and fenced back yard.

Areas off-limits to children include: Three (3) bedrooms, one (1) bathroom, and detached converted garage. Per licensee, the rooms are locked when children are present. LPA observed that doors were unlocked. LPA reminded licensee the off-limits areas of the home are to remain inaccessible when children are present.
NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 198400807
VISIT DATE: 04/17/2025
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The following documents were posted inside the converted garage: Facility License, Notification of Parents' Rights (PUB 394), and Earthquake Preparedness (LIC 9148). LPA reminded licensee that upon approval for a Large Family Chilldcare license, per Fire Inspector the garage can no longer be used for activities and play. Facility Roster (LIC 9040) was available for review. LPA observed Disaster and Fire Drill log. The last drill was conducted on 03/03/2025. LPA reminded Licensee that drills are to be conducted every six months.

Areas used by children were inspected for safety, comfort, heating, cleanliness, and telephone service.


Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting, and ventilation were evaluated. The facility uses central heating and air for ventilation. Lighting was observed to be in operable condition. Inside, LPA did not observe any toys. Per licensee, children play with the toys inside of the converted garage. LPA observed toys inside of bins in the garage. LPA observed five mats and one play yard for napping. LPA reminded Licensee that there shall be one play yard per infant. Per Licensee, there are no bodies of water or firearms on the premises.

Detergents, cleaning compounds, and medicines were made inaccessible to children. Per Licensee, poisons are kept in the locked shed outside. LPA reminded Licensee that poisons are to remain in an area that is locked and inaccessible to children. LPA observed cleaning supplies in an inaccessible cabinet underneath the sink in the kitchen and in the bathroom.

LPA observed the fire extinguisher (2-A:40-B:C) that is fully charged with a service date of 02/04/2025. Licensee was reminded to have the fire extinguisher serviced yearly. LPA observe an operable combination smoke and carbon monoxide detector.



Per Licensee, they provide breakfast, lunch, and two snacks. Licensee was reminded that food that is brought from the children's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of two (2) children's files and 2 personnel files. Based on the children's record review, 2 out of 2 children’s records were missing an infant’s sleep log, Medical Consent (LIC 627), and ID and Emergency Information (LIC 700) form. LPA observed in children files Licensee included forms that were like the Medical Consent and ID and emergency Information forms. LPA advised Licensee to
NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 198400807
VISIT DATE: 04/17/2025
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use The Department issued forms. For the infant sleep log, Licensee stated that they thought infants were any child under age one. LPA reminded Licensee that infants are defined as any child up to age two. Licensee agreed to start documenting infants’ sleep.

Based on the personnel records reviewed, 1 out of 2 staff’s files were missing. LPA observed that staff 2 was missing Employee Rights (LIC 9052), Statement to Acknowledge Child Abuse (LIC 9108), and Mandated Reporter Training Certification. LPA reminded licensee that mandated reporter training must be completed every 2 years. Mandated reporter training is available at www.mandatedreprterca.com. LPA observed that licensee had Pediatric CPR and First Aid training certificate (expires 01/25/2027). Licensee has proof of immunization against pertussis, measles, mumps, and a signed flu declination. Their mandated reporter completion certificate expires on 06/28/2025.

Licensee 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 Childcare 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.

LPA discussed the safe sleep regulations with licensee and discussed the Childcare 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 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.

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/.

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 198400807
VISIT DATE: 04/17/2025
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A fire clearance for a large family childcare capacity 12- 14 was granted on 03/25/2025. Based on the LPA’s observations, the following items must be corrected (along with management approval) prior to obtaining a large family childcare license. Corrections are due by 05/17/2025.

1. Purchase two play yards with fitted sheet for infants.

2. A completed Mandated Reporter training certificate completed by Dajuan Clark.

3. Copies of completed Medical Consent Forms (LIC 627) and ID and Emergency Information (LIC 700) forms for all children enrolled.

4. A completed sleep logs with at least one week of logging infant’s sleep for all infants (children up to age two) in care.

No deficiencies were cited during today’s visit.

Exit interview conducted and report was reviewed with Licensee, Shakeena Clark. The Notice of Site Visit (LIC 9213)-must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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