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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018911
Report Date: 01/23/2026
Date Signed: 01/23/2026 12:42:40 PM

Document Has Been Signed on 01/23/2026 12:42 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:FIELDS-BENJAMIN FAMILY CHILD CAREFACILITY NUMBER:
198018911
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
01/23/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Licensee Shannon Fields- Benjamin TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon, conducted a unannounced visit to follow up on corrections given on 1/9/2026. LPA Calderon met with Licensee Shannon Fields- Benjamin who allowed LPA entrance into the facility. LPA discussed the purpose of today's visit.

LPA Calderon conducted a tour of the facility alongside Fields- Benjamin. LPA observed 2 staff assistants, who were fingerprinted cleared (Staff #1 and Staff #2) and Licensee. All individuals were noted and obtained clearances. LPA observed 7 children, 3 babies and 4 children over the age of 2, no school age children present. At 11:55am Child #7 left making census 6, 3 infants and 3 other children age 2 and older. LPA Calderon offered Technical Support Program, and Licensee Field-Benjamin agreed to be signed up for training. Technical Violation was given.
LPA obtained Declaration Letter from Licensee Fields- Benjamin- informing the dept. Licensee understands what is needed for Clearances/Transfers and Live Scan for employees.LPA Calderon in addition, reviewed corrections from visit 1/9/26- staircase had baby gate in place, infant #1 and #2 had 15 min sleep log, and Licensee stated Staff #1 and #2 will replace staff #3, therefore LPA reviewed personnel records to ensure they are in compliance for Staff #1 and Staff #2. Upon review, LPA Calderon reviewed staff immunization records on 1/6/26 and continued on 1/23/26. On 1/23/26, it was reviewed that Staff #1 is missing TB and Staff #2 Missing TB, MMR and TDAP/DTAP, deficiency cited.
Based on today’s visit, Per California Code of Regulations Title 22 facility was given 1 deficiency for incomplete staff files, missing immunization records. Licensee/ Applicant was advised that approval of the application for a Large Family Child Care will be determined upon review of Department and after correction are completed. Once licensed, the applicant is required to comply with Title 22 and with the terms and limitations stated on the License. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee/ Applicant Shannon Fields-Benjamin,
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/23/2026 12:42 PM - It Cannot Be Edited


Created By: Ashley Calderon On 01/23/2026 at 11:53 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: FIELDS-BENJAMIN FAMILY CHILD CARE
FACILITY NUMBER: 198018911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2026
Section Cited
HSC
1597.622(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
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During visit Licensee informed staff assistant on vaccinations required for employees.
Licensee will provide immunization records for Staff #1 and Staff #2. By POC due date.
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 Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Staff #1 -Needs current TB record.
Staff #2 - Needs current TB, MMR, TDAP/DTAP records.
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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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Ashley Calderon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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