Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 10/17/2016
Date Signed: 10/17/2016 02:54:01 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: 11DATE:
10/17/2016
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Shameka NicholasTIME COMPLETED:
03:12 PM
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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 11 napping children supervised by licensee's assistant. Licensee's spouse was present in the home as well. Licensee arrived shortly after LPA's arrival due to running errands.

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 front yard is off limits while the backyard is used for outdoor activity space.

LPA observed a barricaded fireplace in the living room. There were no detached sheds observed in the home. 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: 10/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2016
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
VISIT DATE: 10/17/2016
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: 6/18/18
-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: 10/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2016
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 10/17/2016
NARRATIVE
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The following deficiencies are cited in accordance with Title 22 of California Code of Regulations and discussed with licensee:

Licensee and staff did not have records of vaccinations.

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: 10/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2016
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 10/17/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2016
Section Cited
1596.7995(a)(1)
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Employees or volunteers at day care center; immunization requirements; records; exemptions

Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been
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Licensee states she will obtain vaccination records for herself and staff members.
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immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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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: 10/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2016
LIC809 (FAS) - (06/04)
Page: 4 of 4