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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500557
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:44:11 PM

Document Has Been Signed on 03/07/2023 04:44 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:FIRST CHRISTIAN CHURCH CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191500557
ADMINISTRATOR:LILIANA VASQUEZFACILITY TYPE:
850
ADDRESS:1751 N PARK AVTELEPHONE:
(909) 629-3636
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 60TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Patricia UbaTIME COMPLETED:
05:00 PM
NARRATIVE
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On 3/7/2023 at 10:00 am a Case management inspection was conducted by Licensing Program Analyst (LPA) Carolyn Tuba. This visit was intiated during a compalanit inspection on the same day. LPA met with Director, Patricia Uba. During the course of the case management visit, Staff #2 (S2) disclosed during interview that she did not advise mom of the injury on 2/27/2023 due to the classroom being hectic that day.

Based on information received, deficiency is cited on attached 809D.

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 comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview was conducted and appeal rights were given to Director, Patricia Uba.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 03/07/2023 04:44 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 03/07/2023 at 03:02 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: FIRST CHRISTIAN CHURCH CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191500557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2023
Section Cited
CCR
101226(a)

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101226 Health-Related Services
(a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.
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Director will hold staff meeting advising the importance of informing parents of injuries and using app ProCare to write injury reports.
Director will hold meeting with staff on 3/10/2023. Director will provide LPA via email an itinerary of meeting and staff signatures.
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To receive safe, healthful ... This requirement was not met as evidence by: Staff not notifying parent of injury to their child.
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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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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