Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 06/20/2016
Date Signed: 06/20/2016 04:06:03 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: 12DATE:
06/20/2016
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Shemaka NicholasTIME COMPLETED:
04:20 PM
NARRATIVE
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ANNUAL/REQUIRED VISIT CONDUCTED IN ENGLISH

An Annual Required visit was conducted by LPA Timothy Fields. LPA was guided on a tour of the facility by Licensee Shameka Nicholas. This is a single story home with three bedrooms and two bathrooms. Residing in the home are 2 adults and one child age 13. Upon arrival LPA observed 12 children alone with licensee's assistant. Licensee was at the store purchasing cushioning material and other restoration items for the backyard. Licensee arrived approximately 30 minutes after LPA's arrival. Children were napping in the living room during today's visit.

Care is mainly provided in the living room and one bedroom located in the hallway. The two remaining bedrooms and guest bathroom are off limits to children in care. LPA observed child proof doorknobs on each door. The kitchen and laundry room is only accessible through passing. Children use the bathroom adjacent to the laundry room. LPA observed a 2 sided floor heater in the hallway area. Licensee has a small dog isolated in an off limits bedroom. The backyard is currently off limits while licensee complete the restoration. The front yard is being used for outdoor activity space.

The front yard is not fenced, therefore licensee was reminded 100% supervision is required at all times. There were no fireplaces or detached sheds observed in the home. LPA did not observe children in a locked care. All rooms that are off-limits need to be made inaccessible during operating hours. Storage areas for poisons, detergents, cleaning compounds, medicines, and other items which pose a danger to children were observed to be inaccessible to children in care. Capacity and ratio was observed to be in compliance.

Licensee complied with inspection authority. Per licensee there are no weapons or firearms in the home. Telephone service was in operable condition. There are no *swimming pool or spa on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors, Carbon Monoxide detector, and fire extinguisher (2A 10BC) are in operable condition. Detectors are wired into a central alarm system.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6


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: 06/20/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2016
Section Cited
102416.5(e)
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Staffing Ratio and Capacity.
If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
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Licensee states she will submit a written plan to ensure the facility is not over capacity.
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Licensee's assistant was left alone with 12 children.
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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: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
LIC809 (FAS) - (06/04)
Page: 4 of 6


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: 06/20/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2016
Section Cited
102417(b)
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Operation of a Family Child Care Home. The home shall be kept clean and
orderly, with heating and ventilation for safety and comfort.
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Licensee opened blinds allowing air to ventilate throughout the living room and also placed a fan in this area during today's visit. Licensee was reminded to keep children hydrated. Licensee states she will purchase a portable A/C.
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During Upon arrival the home was not properly ventilated. The blinds where children were napping where closed and there was no fan or air conditioning system present. temperature reached 90 degrees according the to LPA's thermometer.
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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: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
LIC809 (FAS) - (06/04)
Page: 6 of 6


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: 06/20/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2016
Section Cited
102416(c)
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Personnel Requirements. 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.
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Licensee states she will submit proof of certifications for herself and her assistant by POC date.
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Licensee and licensee's assistant did not have proof of a current Pediatric CPR/First Aid certification.
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Type B
06/22/2016
Section Cited
102417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children.

Licensee did not have a current children's roster.
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Licensee states she update the facility roster by POC date and submit proof.
Type B
06/22/2016
Section Cited
102417g9A1
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Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.

Licensee did not have proof a conducting fire and disaster drills.
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Licensee states she will conduct a drill by POC date and submit proof.
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: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
LIC809 (FAS) - (06/04)
Page: 5 of 6


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
VISIT DATE: 06/20/2016
NARRATIVE
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The following deficiencies are cited in accordance with Title 22 of California Code of Regulations and discussed with licensee:

Facility was over capacity. Licensee's assistant was left alone with 12 children. Licensee and licensee's assistant did not have proof of a current Pediatric CPR/First Aid certification. Licensee did not have a current children's roster. Licensee did not have proof of conducted fire and disaster drills. Upon arrival the home was not properly ventilated. The blinds where children were napping was closed and there was no fan or air conditioning system present. Temperature reached 90 degrees according the to LPA's thermometer.

See 809 D attached.
The licensee shall require each recipient (Parent/guardian) of a licensing report documenting a
Type A citation resulting from a compliant investigation and any licensing document pertaining to a conference, and any summary of an accusation indicating the Department’s intent to revoke a license, to sign
LIC 9224 form, indicating that he or she has received the documents and the date they were received. The licensee shall keep verification of receipt in each child’s file.

Exit interview was conducted with licensee. Appeal rights and procedures explained.
Notice of cite visit posted and Licensee was advised to keep notice posted 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: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
LIC809 (FAS) - (06/04)
Page: 3 of 6


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
VISIT DATE: 06/20/2016
NARRATIVE
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The following was discussed: Individuals who are 18 years of age or older living or working in the home must be finger print cleared prior to licensure or living/working in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. An immediate $100 per day Civil Penalty for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations per individual will be issued. If an individual has a clearance with the Department, a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used.

During operating hours no smoking, no infant walkers, Johnny jumpers, Exersaucers and any other item that falls into that category are allowed in the facility. Earthquake, fire disaster, and safety drill posting requirement were explained in detail on this date.

Licensee has been advised of the following:.
.Pools should be inaccessible by a pool cover or a 5-foot fence around the perimeter of the pool. If the fence is made out of chain link, the opening should not allow a golf ball to pass through. Fences made out of mesh will need to be approved by the department. Mesh fence will remain in place whenever licensed care is provided, and as long as the mesh fence makes the swimming pool inaccessible to children as determined by licensing staff.
· Pool cover label should read F1346-91 American Society for Testing Material and it should be able to withstand the weight of an adult without water above cover when standing.
·Dog(s) and or pets should be isolated from children in care.
·It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

-CPR and First Aid expires: Unknown
-Child Care Roster, Disaster Plan, and Children's Records were discussed.
-Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2016
LIC809 (FAS) - (06/04)
Page: 2 of 6