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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407810
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:10:17 PM

Document Has Been Signed on 03/30/2022 03:10 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 HOUR CHILD CARE INC.FACILITY NUMBER:
197407810
ADMINISTRATOR:PEGGY & PENNY NAIRNFACILITY TYPE:
830
ADDRESS:15300 DEARBORNTELEPHONE:
(818) 892-6635
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 3DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Director: Gloria AvinaTIME COMPLETED:
10:20 AM
NARRATIVE
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On 03/30/2022 at 8:22 a.m., Licensing Program Analyst (LPA) Antonio Almanza conducted an unannounced Case Management Visit at the Probationary Licensed Facility. During today’s visit LPA met with the Director, Gloria Avina, explained the purpose of the visit and toured that facility. When LPA arrived at the facility there were no children in care. A total of 3 children arrived During today’s visit and one teacher.

The Director is reporting that the Dearborn Combination Center operates Sunday through Saturday 24-hours per day. The infant Center operates Monday through Friday 8:30 a.m. to 5:00 p.m. All Adults in the facility have received criminal record clearance and are associated to the facility. Prior to entering the facility, LPA Almanza attempted to conduct a COVID-19 Risk Assessment by calling the facility phone number 3 times, but no one answered the phone.

During today’s visit the following violations are being cited:

1. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, Staff 1 (Gloria Avina) is the Director of the Dearborn Child Care Center location, days of operations are Monday through Saturday from 6:00 a.m. to 3:00 pm. Based on the Documents provided by Peggy Nairn, Staff 1 does not have the qualifications required to be the Director.

2. According to the Personnel Roster (LIC500) received at the Regional Office from the Owner Peggy Nairn, there is no Director scheduled at the Dearborn location Sunday through Saturday 9:00 p.m. to 6:00 a.m., and Sunday 6:00 a.m. Based on the Application for Child Care Center submitted by the Peggy, The facility is operating 24-hrs per day 7 days per week.
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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810
VISIT DATE: 03/30/2022
NARRATIVE
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3. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn and the information provided by staff, the persons assigned as the childcare center directors during the evening, and night programs are assigned classroom teachers. There is no Actual Director on site during these times. The evening and nighttime Directors are assigned to classrooms as teachers when they are supposed to be the Director.

4. Based on information received at the El Segundo Regional Office from the Owner Peggy Nairn, Licensee has not provide 24 hours of quarterly training to staff on mental health assessments, client behaviors, personal rights, care and supervision, and medication and keep a record of staff who attend such training and make records available to Licensing.

5. Per Stipulation Waiver; and Order no staff shall work more than 8 hours per day, Based on information provided by Facility Staff, they have been working over 8 hours per day.

6. During the Case Management visit conducted on 03/28/2022, LPA did not observe Personal Rights Form LIC-613A, posted in a location were parent in the Child Care Center can see them. The Notice that was posted inside the facility in an inaccessible location has a phone number to an LPA with the El Segundo Children’s Residential program, and this LPA phone number. The form does not have the El Segundo Regional Office telephone number.

7. During the Case Management visit conducted on 03/28/2022, LPA did not observe Child Care Center Notification of Parents' Rights Poster PUB 393, posted in a location were parents in the Child Care Center can see it. The Notice has this LPA contact information and does not have the El Segundo Regional Office telephone number.

8. During the Case Management visit conducted on 03/28/2022, LPA did not observe the Child Care Center license in area where parents can see it during pick up and drop off.

9. LPA attempted to verify the facility phone number (818) 892-6635 was correct and operating. LPA was able to verify the phone was operating and located in the Directors office.

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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810
VISIT DATE: 03/30/2022
NARRATIVE
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It was explained to the Director, the importance of the facility having a functioning phone and staff attending to the phone, because the call may be related to an emergency that can affect the Health and Safety of Children in Care.

10. During the Case Management visit conducted on 03/28/2022, LPA observed the ceiling of the infant room licking water. During the vist it was raining and their were no children in care.

During today’s visit the following violations are being cited under Title 22 Regulations, Division 12, Chapter 1, of the California Code of Regulations, and Health & Safety Code. There are ten (10) Type B violations (please see LIC 809-D for cited deficiencies).

During today’s visit two Civil Penalties for Repeat Violations were issued on LIC421FC.


A copy of this Report (809 &809D) and appeal rights were explained and provided to the Director Gloria Avina. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

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SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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Page: 2 of 8
Document Has Been Signed on 03/30/2022 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/30/2022 at 11:20 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 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101215.1(h)(1)

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101215.1(h)(1) Child Care Center Directors Qualifications and Duties, High school graduation or GED; completion, with passing grades, of 15 semester or equivalent quarter units as specified in (h)(1)(A) and (h)(1)(B) below at an accredited or approved college or university...
This requirement is not met as evidenced by:
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Liensee will provide veification of Director Qualifications to the LPA by 04/01/2022 or find a Replacement for the Director.
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Based on records review, Staff 1 does not have the qualifications to be Director, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Type B
04/01/2022
Section Cited
CCR101215.1(d)

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101215.1(d) Child Care Center Directors Qualifications and Duties, The child care center director, or the substitute director as specified in (f) below, shall be on the premises during the hours the center is in operation.
This requirement is not met as evidenced by:
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Licensee will submit an updated Personnel Record Lic500 demonstrating that there is a Director During the hours the Child Care Center is in operation.
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Based on observation and records review, The Licensee does not have a Director assigned to the Facility During all hours of operation, which poses a potential Health or Safety, 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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Page: 4 of 8
Document Has Been Signed on 03/30/2022 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/30/2022 at 11:26 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 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101215.1(c)

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101215.1(c) Child Care Center Directors Qualifications and Duties,The child care center director shall be responsible for the operation of the center, for compliance with regulations, and for communications with the Department...

This requirement is not met as evidenced by:
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Licensee will make sure to have a Director assigned to the Evening and Night programs that is not in the classroom as a teacher. Licensee will provide copy of Personnel Roster with proper staffing for the facility during the programs.
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Based on interviews, The Licensee does not have a Director During the Evening and Night progrmas, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Licensee will provide copy of Personal Roster with proper staffing for the facility during hoursof operation by 04/01/2022.
Type B
04/01/2022
Section Cited
CCR101216

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101216(e)Personnel Requirements, All personnel shall be given on-the-job training... Per Stipulation Licensee shall provide 24 hours of quarterly training and keep a record of staff who attend such training and make records available to Licensing.
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Licensee shall comply with the Stipulation and Waiver; and Order, and provide the 24 hours of training to staff and submit a copy of the records of staff who attended the training on required subjects to LPA by 4/01/22.
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Based on observation and records review, The Licensee does not have records available for the 24 hours of quarterly training, which poses a potential Health or Safety, 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/30/2022 at 11:32 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 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101216(l)

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101216(l) Personnel Requirements (l) All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code.
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Per Stipulation no employee shall work more than eight (8) hours per day. The director shall immediately ensure that no staff is working more than 8 hours per day.
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Based on records review staff have been working more than 8 hours, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Director will provide LPA with copy of the staff time cards from 03/01/2022 to 03/30/2022 and provide a Mitigation Plan demonstrating how the facility will ensure to be fully staffed at all times and that no employee shall work more than eight (8) hours per day by end of day 4/01/22
Type B
04/01/2022
Section Cited
CCR101223(b)(2)

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101223 (b)(2) Personal Rights, The center shall post a copy of the LIC 613A (9/96) in a prominent, publicly accessible area in the center.
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Director will post Personal Rights Form LIC-613A where parents can have access to it during pick up and dropp off.
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Based on Observation a copy of the LIC 613A is not posted in a prominent, publicly accessible area of the center, which poses a potential health, safety 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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Page: 6 of 8
Document Has Been Signed on 03/30/2022 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/30/2022 at 11:36 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 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
101218.1(c)

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101218.1 Admission Procedures and Parental and Authorized Representative's Rights
(c) The licensee shall post the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster in a prominent, publicly accessible area in the child care center at all times.
This requirement is not met as evidenced by:
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Director will post PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster where parents have access to it during pick up and drop off.
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Based on Observation a copy of the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster is not posted in a prominent, publicly accessible area of the center, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/08/2022
Section Cited
CCR101238(a)

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101238 Buildings and Grounds, (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
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Licensee will have the roof in the Infant room repaired so that when it rains again it does not leak water or create water damage. Licensee will provide documetation of repairs by 04/08/22
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Based on Observation the celing in the infatn room was leaking water, which poses a potential health, safety 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 03/30/2022 03:10 PM - It Cannot Be Edited


Created By: Antonio Almanza On 03/30/2022 at 11:50 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 HOUR CHILD CARE INC.
FACILITY NUMBER: 197407810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
HSC
1596.8555

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Health and Safety Code, 1596.8555 Posting of License , A licensed child day care facility shall post its license in a prominent, publicly accessible location in the facility.
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Licensee will make sure License is posted in an accessible location where parents can see it during pick up and drop of.
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Based on observation the facility License was not posted in area where the parents can see it during pick up and drop of, which poses a potential Health or Safety, 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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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