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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407318
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:31:45 PM

Document Has Been Signed on 07/12/2022 12:31 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: 11DATE:
07/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Director Tina RobertsTIME COMPLETED:
12:37 PM
NARRATIVE
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On 07/12/2022 at 10:38 a.m., Antonio Almanza, Licensing Program Analyst (LPA), conducted an unannounced site visit for the purpose concluding investigation regarding a self reported Unusual Incident Report (UIR) that occurred on 04/27/22. LPA met with Tina Roberts, Director, and explained the purpose of the visit. During today’s visit LPA toured the facility and observed 11 children and 3 Adults providing care and supervision.

According to the information provided on the UIR received, via email on 05/05/22, On 0427/22 there were children in the bathroom washing their hands when Child 1 (C1) splashed water on Child 2 (C2). C2 told Staff 3 (S3) that C1 put water on C2s head. S3 put water on C1s head and flicked water at C1. According to the UIR Staff 2 (S2) overheard part of the conversation and informed the Director Staff 4 (S4).

Staff 2 is reporting that the incident happened before lunch. When S2 arrived to the classroom C1 told S2 that S3 threw water on C2s head. S2 was not present at the time of the incident and believes the incident happened in the bathroom. S2 is reporting that S2 observed that C1 was wet from C1s head and was dripping a little bit of water.

Staff 3 is reporting that on the date of the incident S3 was supervising the children in the bathroom while standing next to the table, in front of the bathroom. S3 reported that when S3 saw the two children they were not splashing water in the bathroom but then C2 went running to S3 and told S3 that C1 was throwing water. S3 went up to C1 and said, “did you do this” and C1 said yes. C1 was “laughing like crazy and laughing at C2.” S3 became angry and reacted by grabbed a cup from the snack table; and poured water on C1s head and C1 started crying. S3 cleaned C1 up and told C1 not to do it anymore.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407318
VISIT DATE: 07/12/2022
NARRATIVE
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The facility failed to submit a timely Unusual Incident Report (UIR) over the phone and in writing. The incident happened on 04/27/22; the incident was reported via email on 05/05/22. On 05/06/22, LPA returned a call to the facility after receiving a voicemail from S4 informing LPA of a UIR. S4 reported that on 04/27/22 S4 called the El Segundo Child Care Regional Office and reported the Incident to the On Duty Worker (OD). S4 could not give the name of the OD that took the call. LPA contacted the assigned OD for 04/27/22 to inquire about the incident as there were no record of the call or incident. The OD stated that no call was received from any staff member from Penny & Peggy 24-hour Child Care facilities.

During today visit there are Three Type A violation are being cited under Health & Safety Code (H&S) and California code of Regulations, Title 22, Division 12, Chapter 1 (see LIC809D for details).

1. H&S - 1596.885 (c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.

2. Tittle 22 – 101229 (a)(1) Responsibility for Providing Care and Supervision - (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2 (e)(1) and 101230(c)(1). Supervision shall include visual observation.

3. Title 22 - 101212 (d) Reporting Requirements, (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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 containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

A copy of this report must be provided to the authorized representatives of all currently enrolled children and any newly enrolled child for the following 12 months. The ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC9224) shall be signed and kept in each of the children’s records. The report shall be provided no later than the next business day or the next day the child is in care.

This Report and The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation, Failure to maintain posting as required will result in a civil penalty of $100.00.

A copy of this Report (809 & 809D), Appeal Rights, Acknowledgment of Receipt of Licensing Report (LIC 9224), and Notice of Site Visit (LIC 9213) were provided and explained to the Director Tina Roberts.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/12/2022 12:31 PM - It Cannot Be Edited


Created By: Antonio Almanza On 07/12/2022 at 11:15 AM
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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited
HSC
1596.885(c)

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596.885(c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.
This Requirement is not met as evidenced by:
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Director will write a memo and discuss with all staff proper and inappropriate interactions with children as well as behavior management and Staff self control.
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Based on interview and record review, S3 became angry and poured water on C1s head and C1 started crying , which poses an immediate and Health and Safety, and personal rights risk to persons in care.
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Director will provide LPA a copy of memo with signatures from all staff and facility
Type A
07/13/2022
Section Cited
CCR101229(a)(1)

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101229(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation.
This Requirement is not met as evidenced by:
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Director will write a staff memo on supervision and staff positioning while conducting variouse activities in the facility.
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Based on interview and record review, Staff 3 did not observe children in bathroom splashing water resulting in S3 reacting inapropriately, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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Director will provide memo with staff signatures to LPA and facility Roster.
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:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2022 12:31 PM - It Cannot Be Edited


Created By: Antonio Almanza On 07/12/2022 at 11:33 AM
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: PENNY AND PEGGY NAIRN 24-HR CHILDCARE INC.
FACILITY NUMBER: 197407318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited
CCR
101212(d)

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101212(d) Reporting Requirements, (d) Upon the occurrence... 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... a written report shall be submitted... within seven days following the occurrence of such event.
This Requirement is not met as evidenced by:
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Director will write a statement on understating of Tittle 22 regulations regarding reporting requirements for Unusual Incident Reports.
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Based on interview and record review, The Licensee did not submit a UIR per Title 22 Regulations and alleged that UIR was submitted and no proof of it, which poses an immediate Health and Safety, and or personal rights risk to persons 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:Lisa Rios
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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