Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 05/04/2018
Date Signed: 05/04/2018 12:23:30 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: 8DATE:
05/04/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Shameka NicholasTIME COMPLETED:
12:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced random annual inspection. LPA met with licensee's assistant Maria Ochoa who guided this LPA on a tour of the facility. LPA talked with licensee over the phone. Licensee stated she recently had surgery and went to the doctor for a check up. There were 8 children present during today’s inspection. Assistant states that there are currently 12 children enrolled. The children's roster was reviewed and is current. Disaster drill log was also available during today’s inspection.

This is a one story home which consists of 3 bedrooms and 2 bathrooms. Day care is provided in the living room, 1 bedroom, and the front yard. Assistant was reminded that direct supervision is required when outdoor play area is not fenced. Per licensee, areas off limits to children and parents include: 2 bedrooms, 1 bathroom, kitchen, and back yard.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. Family members residing in the home are 2 adults (criminal record clearances on file) and 1 child. Per assistant, there is a pet dog. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. The licensee states that there are no poisons in the home.

Per licensee, there are no weapons, firearms or bodies of water on the premises. There are safe toys, play equipment and materials observed for children. Emergency Disaster Plan was posted at the time of inspection. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged but was last serviced over a year ago. Smoke and carbon monoxide detectors in the hallway were tested and are in operable condition.
Report continues- Page 1 of 3
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
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 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: 05/04/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2018
Section Cited
HSC
1597.622(a)(1)
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Employees or volunteers at family day care home; immunization requirements; records; exemptions

Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not
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Licensee will submit proof of immunization against influenza, pertussis, and measles to LPA by the POC date.
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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.
Proof of immunization was not provided to LPA during today's inspection.
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Type B
05/18/2018
Section Cited
CCR
102417(g)(1)
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Operation of a Family Child Care Home

Fire extinguishers and smoke detectors shall meet State Fire Marshal standards.

LPA observed fire extinguisher was last serviced over a year ago.
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Licensee will have fire extinguisher serviced and submit proof of service to LPA by the POC date.
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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: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
LIC809 (FAS) - (06/04)
Page: 4 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: 05/04/2018
NARRATIVE
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LPA issued the Confidential Names List (LIC 811) to the licensee during this visit. The Confidential Names List documents the children’s files that were reviewed during this inspection.

The deficiencies listed on the following page were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Exit interview was conducted with Licensee' s assistant. The assistant was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

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 $100.00.


Report ends- Page 3 of 3
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
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
VISIT DATE: 05/04/2018
NARRATIVE
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The licensee and assistant have current Pediatric First Aid and CPR, which will expire on 06/2018. Licensee and assistant did not provide proof of immunization against influenza, pertussis, and measles to LPA during today's inspection.

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.

LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. A hard copy of A Child Care Provider’s Guide to Safe Sleep was provided.

Incidental Medical Services (IMS): The Licensee states that she will not administer any medication. If the Licensee chooses to administer prescription medication in the future, she must refer to California Title 22 Regulations Section 102417 for additional information on regulatory requirements.

Report continues- Page 2 of 3
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
LIC809 (FAS) - (06/04)
Page: 2 of 4