197407811-3-10-2023-58-CC-AALA-CPSW58-20230310155844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197407811
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:59:29 PM

Document Has Been Signed on 03/10/2023 03:59 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:	PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.		FACILITY NUMBER:	197407811
ADMINISTRATOR:	MAGALY ZUNIGA		FACILITY TYPE:	850
ADDRESS:	15300 DEARBORN		TELEPHONE:	(818) 892-6635
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 25	TOTAL ENROLLED CHILDREN: 272	CENSUS: 20	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Director Tina Roberts		TIME COMPLETED:	04:15 PM

NARRATIVE

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On 03/10/2023 at 9:48 AM, Antonio Almanza, Licensing Program Analyst (LPA), conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Tina Roberts, Director and Gabriela Hovey, Administrator, and toured the facility indoors and outdoors. Days and hours of operation are seven day per week 24 hours per day.

The facility is located inside a combination center(home like structure) with Infant License (197407810) and School Age License (197407812). The preschool is located in the front main entrance of the facility. The preschool has one large room and bathroom located within. The playground is located in the back of the facility and children have to walk around the facility through the school age playground to get the preschool playground.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible and stored in the facility office. All poisons are kept in a locked storage area of the office.

Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents.

Facility has a functioning smoke and carbon monoxide and LPA verified they are operational. Facility has first aid kit in the office. The facility has two fire extinguishers in the classroom that were serviced on 05/27/22. Pg 1

SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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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Document Has Been Signed on 03/10/2023 03:59 PM - It Cannot Be Edited

Created By: Antonio Almanza On 03/10/2023 at 02:36 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.	FACILITY NUMBER: 197407811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(g)(1)

Personnel Requirements

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in Staff 4 does not have a complete Helath Screaning Report LIC503 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Facility will get a complete Helath Screaning Report LIC503 from staff 4 and provide LPA a copy.

Type B

Section Cited

CCR

101229.1(b)

Sign In and Sign Out

(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that Child 6 was not signed in during drop off and Child 7 was signed out but still in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Director agrees to provide Staff with reminder that the person who brings the child and removes the child from the center shall sign the child in and out. Director will have staff sign off that they have been given instructions on procedures for sign in/sign out and provide to LPA.

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:

Betty Bell

LICENSING EVALUATOR NAME:

Antonio Almanza

LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.	FACILITY NUMBER: 197407811
	VISIT DATE: 03/10/2023

NARRATIVE

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Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. No individuals excluded by the Department are allowed to be present.

Capacity and limitations as specified on the license are being maintained. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility. The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department.

Director was reminded that children shall be under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child. Upon arrival, LPA reviewed sign in and sign out sheets for children and observed Child 6 was not signed in and Child 7 was signed out but still present in the facility. The facility sing in and sign are not able to capture the 24 hour activities and create discrepancies based on Director not being able to clearly account for children’s where about.

LPA reviewed a sample of staff files and observed files were complete with documentation of meeting qualification requirements, immunization records for influenza, pertussis and measles. Staff 4 has an incomplete LIC503 Health Screening Report on file.

Facility has all required posting and menus are posted at least one week in advance where an authorized representative can view them in the entrance of the facility.

Per Stipulation Waiver and Order the facility is required to post Stipulations and Accusation in a conspicuous place in the facility. The facility has Stipulation and Accusation posted in the entrance of the facility.

Per Stipulation Waiver and Order all parents are to receive a copy of Stipulation and Accusation. Parents shall sing an acknowledgement indicating they have received a copy of the Stipulations and Accusation and sing of that they received a copy; Children’s files have LIC9224 acknowledging receipt of Stipulation and Accusation.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.	FACILITY NUMBER: 197407811
	VISIT DATE: 03/10/2023

NARRATIVE

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Per Stipulation Waiver and Order Section C, no employee shall work more than 8 (eight) hours per day. According to the Administrator and Director they have reporter UIRs as required to the Regional Office for 3 staff working over 8 hours on two different occasions. This is in violation of Stipulation Waiver and order.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During today’s visit Two Type B violations are being issued under Title 22 Regulations, Division 12, Chapter 1, of the California Code of Regulations:

1. 101216(g)(1), Personnel Requirements, 1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

2. 101229.1(b), Sign In and Sign Out, (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 03/10/2023 03:59 PM - It Cannot Be Edited

Created By: Antonio Almanza On 03/10/2023 at 02:55 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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.	FACILITY NUMBER: 197407811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(l)

101216(l) Personnel Requirements, All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in that the Adminsitrator and Director have reported that staff have been working more than 8 hours which is in Violation of Stipulation, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Director agrees to provide facility staff with the facility Mitigation Plan, that was previously provided to LPA on 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. Facility staff will sign off that they have received and reviewed mitigation plan.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Betty Bell

LICENSING EVALUATOR NAME:

Antonio Almanza

LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: PENNY AND PEGGY NAIRN 24 HOUR CHILD CARE INC.	FACILITY NUMBER: 197407811
	VISIT DATE: 03/10/2023

NARRATIVE

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The following 2 Technical Violations were issued:

1. Children Records - Technical Violation: 101229.1(a)(1) - The facility is operating 7 days per week 24 hours per day and the time children are brough to the facility or removed is not clear. Records do not show that parents are putting AM or PM during pick up and drop of which creates a discrepancy when reviewing records.

2. Children Records - Technical Violation: 101229.1(c) - The facility has children that are being taken to school and picked up from school but the sign in and out sheet does not clearly capture this information.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. A copy of this report, Appeal Rights (LIC9058) and Notice of Site Visit were reviewed and provided to the Director Tina Roberts and Administrator Gabriela Hovey.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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