Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017228
Report Date: 07/25/2018
Date Signed: 07/25/2018 12:00:03 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: 10DATE:
07/25/2018
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Shameka RobinsonTIME COMPLETED:
12:10 PM
NARRATIVE
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This case management inspection was conducted by Complaint Specialist - LPA Karen Chambers, who met with Shameka Nicholas Licensee.

During this inspection the following was observed and is being cited in accordance with Title 22, California Code of Regulation:

1. The roster that was provided during this inspection was observed to be incomplete, i.e date of birth, date of enrollment and physician info missing.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. This notice shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted with the Licensee, during which appeal rights were explained. A copy of the appeal rights (LIC9058 01/16) were provided. The Licensee’s signature on this report acknowledges receipt of her rights.

SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)981-3368
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2018
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: 07/25/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2018
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children. The requirement is not met as evidenced by: The facility roster provided was observed to not have the date of births, date enrolled and/or physician information for the children listed.
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Per Licensee: I will sit down right now and complete myself with correct and accurate information.

Will fax copy.
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This poses a potential risk to the health & safety to the children in care
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)981-3368
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2018
LIC809 (FAS) - (06/04)
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