Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403006
Report Date: 07/14/2017
Date Signed 07/14/2017 02:59:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME:OLMSTEAD FAMILY DAY CAREFACILITY NUMBER:
197403006
ADMINISTRATOR:OLMSTEAD, MAY A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 385-1147
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:14CENSUS: 6DATE:
07/14/2017
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:May Olmstead, LicenseeTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Tiffanie Tran and Christopher Garlington conducted an unannounced complaint visit at the above facility. LPAs met with May Olmstead licensee.

During files reviewed, LPAs observed children #2, 3, 4 and 6 were missing the blue immunization form.

The facility has been cited for Type B deficiency during today's visit.

An exit interview was conducted. LPAs provided licensee a copy of this report.
SUPERVISOR'S NAME: Sharon GreeneTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2017
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: OLMSTEAD FAMILY DAY CARE
FACILITY NUMBER: 197403006
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2017
Section Cited
102418(g)
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Immunization: Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPAs did not observe the blue immunization records in children # 2, 3, 4 and 6.
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Licensee agrees to complete blue immunization form for children #2, 3, 4 and 6 then will fax or mail copy of immunization records to CCL by 7/28/18 in order to clear this citation.
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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: Sharon GreeneTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2