197495524-1-29-2025-30-CC-TCHS-DDDR4V-20250129114210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495524
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:50:36 AM

Document Has Been Signed on 01/29/2025 11:50 AM - 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	SMITH FAMILY CHILD CARE		FACILITY NUMBER:	197495524
ADMINISTRATOR/ DIRECTOR:	JACQUELYN SMITH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 704-9305
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90731
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	01/29/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:20 AM
MET WITH:	Jacquelyn Smith		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/29/2025 Licensing Program Analysts (LPA) Tyra Chavies conducted an announced inspection with applicant Jacquelyn Smith for the purpose of a pre-licensing inspection. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes. The applicant is applying for a Large Family Child Care Home for a maximum capacity of 14 and has been given an approved fire clearance by Henry Medina. Living in the home are two adults, Chidinma Ujoumunna (Roommate) and Jaquelyn Smith (Applicant). Control of property was submitted to the El Segundo Office for review. Present during today’s inspection was applicant, Jacquelyn Smith. LPA Chavies confirmed the telephone number is: (310) 530-0158. Per the application, at this time, the ages the applicant wishes to provide services for are newborns to 13 years of age with the hours of Monday- Friday 7:30 a.m. to 6:00 p.m. Applicant informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes; an updated LIC 279 will need to be submitted. Breakfast and lunch as well as PM snacks will be provided by the facility.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197495524
	VISIT DATE: 01/29/2025

NARRATIVE

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LPA toured the inside and outside of the home. Inside the home there are two bedrooms, two bathrooms, a living room, a family room, a dining room, a kitchen, a laundry room and a den. Outside the home there is a detached garage which has been converted into a ADU, front yard and backyard, both are fenced in, and a basement. The following areas will be off limits: bedroom 1, bedroom 2, bathroom 1, kitchen, dining room, front yard, basement and detached garage. There are locked doors that make the kitchen and the dining room inaccessible to children in care. Applicant states that the doors will remain locked during operation hours. The following will be accessible to children in care: living room, family room, bathroom 2, den area, laundry room, and back yard. The living room and family room will be used for the main play area/ learning area. LPA observed cots/pack and play for sleeping, age-appropriate toys, and books in primary care area. Children will be sleeping in the living room area and eating in the family room. Because the primary area is in the front of the house and the facility bathroom is in the back of the house, applicant stated the children will be escorted to the bathroom by her or a staff member and walked back to primary area. Because the house is large in size, applicant stated the children will be escorted through the house and lead out of the back door to the backyard. LPA Chavies observed the ADU to be in front of the backyard, where the children will be playing. Applicant has filled out a LIC 855 stating that once a tenant is found, the children and the tenant will not interact during the hours that the facility is in operation. The applicant also stated the children will be supervised at all times while at the facility.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197495524
	VISIT DATE: 01/29/2025

NARRATIVE

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LPA Chavies discussed Safe Sleep Regulations and resources with applicant. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. All cribs or play yards shall meet the United States Consumer Product Safety Commission safety standards. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan will need to be completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Review of records to be maintained - Family Child Care Homes
LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Applicant was made aware that state law prohibits baby walkers, bouncy seats, saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.

The following corrections will need to be completed by 02/05/2025

Child safety locks for cabinets in hallway and for cabinets by bathroom 2
Chidinma Ujoumunna TB Test Results

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197495524
	VISIT DATE: 01/29/2025

NARRATIVE

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The following was discussed with the Licensee:
Incidental Medical Services (IMS) - Family Child Care Homes
APPLICANT KNOWS PROSPECTIVE CLIENTS WILL NEED IMS:
This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
Immunizations
Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.
Criminal Record Clearance - Family Child Care Homes
Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197495524
	VISIT DATE: 01/29/2025

NARRATIVE

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Safe Sleep - Child Care Centers and Family Child Care Homes
LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
MyChildCarePlan.org – Centers and Family Child Care Homes
Applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197495524
	VISIT DATE: 01/29/2025

NARRATIVE

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Megan’s Law - Family Child Care Homes
On this date, 11/18/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
Appeal Process
A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment..

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the applicant, Jacquelyn Smith.

This home is approved for licensing on 01/29/2025, pending manager file review.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Tyra Chavies
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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