Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 05/02/2016
Date Signed: 05/02/2016 12:45:53 PM

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:NICHOLAS FAMILY CHILD CAREFACILITY NUMBER:
198017228
ADMINISTRATOR:NICHOLAS, SHAMEKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 788-0855
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: 9DATE:
05/02/2016
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Shameka NicholasTIME COMPLETED:
01:00 PM
NARRATIVE
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A Case Management visit was conducted by LPA Timothy Fields. LPA met with licensee Shameka Nicholas who guided analysts on a tour of the facility. While touring the backyard LPA observed the majority of the lawn to be covered with dirt. Children were observed playing in this area causing clouds of dirt and dust. Children and play equipment was observed to be effected by the condition of the lawn. Licensee acknowledged the lawn is an issue that needs to be addressed. LPA observed a barbecue pit without the proper locking mechanism or cover. Licensee did not have locking mechanisms or barriers for the off limits bedrooms. Pictures where taken of the backyard.

The following deficiencies are cited in accordance with Title 22 of California Code of Regulations and discussed with licensee: Operation of a family child care home.
Exit interview was conducted with licensee and appeal rights and procedures were explained. Licensee was instructed to post notice of site visit for 30 days.

Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2016
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: NICHOLAS FAMILY CHILD CARE
FACILITY NUMBER: 198017228
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2016
Section Cited
102417(g)
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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child.

LPA observed the lawn in the backyard in need of grass or other material that would prevent the amount of dirt children are exposed to.
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Licensee states the lawn, off limits bedrooms, and barbecue pit will be corrected by POC date and pictures submitted as proof.
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The barbecue was observed without the proper locking mechanism or cover. The off limits bedrooms were observed without locking mechanisms or barriers.
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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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2016
LIC809 (FAS) - (06/04)
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