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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493819
Report Date: 09/28/2022
Date Signed: 09/28/2022 05:03:15 PM

Document Has Been Signed on 09/28/2022 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MORALES FAMILY CHILD CAREFACILITY NUMBER:
197493819
ADMINISTRATOR:MORALES, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 350-1860
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Maria Morales, Licensee and 2 assistantsTIME COMPLETED:
05:10 PM
NARRATIVE
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On 09/28/2022, 3:11PM, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management - deficiencies for the purpose of the health and safety of the family child care. LPA observed 9 children present, who 6 were infants.
During this inspection, Licensee disclosed that on 7/23/2022 the Landlord submitted a notice requesting her to move out from the house. Per Licensee, she did not report this incident.

LPA provided a copy of Unusual Incident Report form (LIC624) and LPA obtained of copy of Unusual Incident Report (LIC624) from Licensee.

LPA is providing a Link from Child Care Licensing Division website, that will help to training to submit futures reports requirement. Please see link below:

https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/


After, Licensee watch the video. Licensee will conduct a training showing this video to all staff. Licensee will submit to LPA Miranda a copy of the agenda along staff signature. In additional, Licensee, will provide a statement (no later than 10/07/2022) answering the following questions:
1. What reports am I required to submit to Licensing?
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MORALES FAMILY CHILD CARE
FACILITY NUMBER: 197493819
VISIT DATE: 09/28/2022
NARRATIVE
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2. How and when should I file these reports?

3. Am I required to file reports with agencies other than Community Care Licensing?

4. What happens when I file a report?

Just remind the Licensee that Upon the occurrence, during the operation of the family child care of any of the events specified in title 22, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report (form: LIC624 Unusual Incident report (UIR) no later than 7 days.

Child Care Advocate information was provided to Licensee.

Also, during this case management, Licensee was unable to produce copies of the safe sleep log for the 6 infants present today. On 09/26/2022 LPA provided a technical violation for Licensee for do not have the safe sleep log for the infants were present that day. Today, Licensee was unable to produce, safe sleep log for the days 09/27/2022 and 09/28/2022.

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Maria Morales, Licensee.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2022 05:03 PM - It Cannot Be Edited


Created By: Denise Miranda On 09/28/2022 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MORALES FAMILY CHILD CARE
FACILITY NUMBER: 197493819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
102416.(b)

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Report Requirement: (b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
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LPA provided a copy of LIC624 Unusual Incident Report. Licensee provided a copy of unusual incident report form to LPA. LPA provided a link that Licensee agreed to watch and after to watch Licensee will
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This is not met the requirement by evidencee by 09/29/2022, Licensee did not report the letter that she received from her landlord on 7/2022.This poses potential risk for the chidlren in care.
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answer the question that was provided on lic809 report. Licensee will submit her answers no later than 10/7/2022. Also, LPA provided the email address from the Child Care Advocates to Licensee.
Type B
09/29/2022
Section Cited
CCR102425(j)(2)(A)(B)(C

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Infant Safe Sleep: (2) The provider shall check & doc. the following: (A) Labored breathing.(B) Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.(C) Infants up to 12 month of age who are sleeping in a position other than on their back. This requirement is not met as evidenced by: on 09/29/2022 LPA reviewed files and Licensee confirmed that she was unable to produce the safe sleep log for the 6 infants in care.This poses potential risk for the children in care.
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Licensee agreed to submit the safe sleep log for the infants in care. For the day 09/29/2022. Licensee understand that safe sleep log shall be log for every infant every 15 minutes while they are sleep.

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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:Lisa Rios
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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