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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494774
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:06:31 PM

Document Has Been Signed on 03/16/2022 03:06 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ALLEN FAMILY CHILD CAREFACILITY NUMBER:
197494774
ADMINISTRATOR:BEVERLY S ALLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 505-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Licensee Beverly AllenTIME COMPLETED:
12:35 PM
NARRATIVE
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On 03/16/2022, Licensing Program Analyst (LPA) Sabrina Martinez conducted a Case Management- Deficiencies visit for the purpose of citing for the deficiencies that were observed during the visit on 03/16/2022.

LPA met with Licensee Beverly Allen. There were 10 children in care being supervised by Licensee, Staff #1, Staff #2, and Staff #3.

On 03/16/2022, LPA requested for the following documents: Child Care Facility Roster, Staff #1's records, and Child #1's records. Licensee stated she does not have a record on file for Staff #1 and Child #1. LPA was unable to review and obtain personnel and children's records.

The facility was issued Type B citations in violation of Title 22 regulations. (See LIC 809-D for deficiency page).

An exit interview was conducted with Licensee Beverly Allen. A copy of this report, Notice of Site Visit, and appeal rights were provided to Licensee.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Sabrina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 2
Document Has Been Signed on 03/16/2022 03:06 PM - It Cannot Be Edited


Created By: Sabrina Martinez On 03/16/2022 at 02:45 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: ALLEN FAMILY CHILD CARE
FACILITY NUMBER: 197494774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
CCR
102416.1(d)

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Personnel Records. All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This requirement is not met as evidenced by: On 03/16/2022, LPA Martinez conducted a review of records and did

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LPA Martinez provided Licensee with a copy of the LIC 311D FORMS/RECORDS TO KEEP IN YOUR FAMILY CHILD CARE HOME.

Licensee Beverly Allen stated she will submit Staff records via email no later than close of business on March 17, 2022.
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not observe records for facility staff. Licensee stated she did not have records on file for employees. This is a Type B citation and poses a potential health and safety risk to children in care.
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Type B
03/17/2022
Section Cited
CCR102421(b)

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Child's Records. The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement is not met as evidenced by: On 03/16/2022, LPA Martinez conducted a review of records and did
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LPA Martinez provided Licensee with a copy of the LIC 311D FORMS/RECORDS TO KEEP IN YOUR FAMILY CHILD CARE HOME.

Licensee Beverly Allen stated she will submit Child #1's records via email no later than close of business on March 17, 2022.
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not observe LIC 700 and other records for Child #1. Licensee stated she did not have records on file for Child #1. This is a Type B citation and poses a potential health and safety risk to 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:Maureen Neal
LICENSING EVALUATOR NAME:Sabrina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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