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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407318
Report Date: 05/16/2022
Date Signed: 05/16/2022 01:05:29 PM

Document Has Been Signed on 05/16/2022 01:05 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:PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.FACILITY NUMBER:
197407318
ADMINISTRATOR:PEGGY NAIRNFACILITY TYPE:
850
ADDRESS:9213 COLUMBUS AVENUETELEPHONE:
(818) 892-6634
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 42TOTAL ENROLLED CHILDREN: 42CENSUS: 13DATE:
05/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Director: Tammy JacquinTIME COMPLETED:
12:20 PM
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On 5/16/22 at 9:13 a.m., Licensing Program Analysts (LPA) Antonio Almanza conducted an investigation regarding a self reported Unusual Incident Report (UIR) that occurred on 04/27/22. LPA met with Administrator Tammy Jacquin and explained the purpose of the site visit. LPA toured the facility and observed 13 children and 2 Adults present at the time of the inspection.

LPA conducted interviews and obtained copies of facility roster and incident reports. Due to insufficient information available at this time, the above mentioned UIR needs further investigation.

A copy of this Report and Notice of Site visit were provided to the Administrator Tammy Jacquin.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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