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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192009032
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:04:58 PM

Document Has Been Signed on 07/31/2024 03:04 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:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
192009032
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, YRAYDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 344-7214
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
07/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:12 PM
MET WITH:Yrayda HernandezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 7/30/24, at 1:12pm, Licensing Program Analyst (LPA) Jeanine Lipsey conducted an unannounced Case Management - Deficiencies visit and was met by Licensee Yrayda Hernandez of whom led LPA on a tour the facility. The facility was in compliance of capacity and ratio. LPA observed 13 children present, 1 of which was an infant, being supervised by 2 staff.

LPA reviewed staff and children's files and discovered C4 & C5 are missing immunization's, C1 Missing LIC 282 and LIC 627. Licensee stated the forms were given to the parents but not returned. Licensee states they will get children's immunization's by Proff of correction (POC) date.


Deficiencies were cited and must be corrected by 8/7/24.

Appeal rights were given, exit interview was conducted and a copy of this report was provided to Licensee Yrayda Hernandez.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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
Document Has Been Signed on 07/31/2024 03:04 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 07/31/2024 at 02:21 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 192009032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
102418(a)

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Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
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Licensee will send proof of immunizations by:
8/7/24.
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Based on record review, the licensee did not comply with the section cited above in that did not poses proof of immunizations records for C4 & C5 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/31/2024
Section Cited
CCR102417(g)(8)

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 Operation of family childcare home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
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Licensee will send proof of completed rooster by:
8/7/24.
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Based on observation and record review, the licensee did not comply with the section cited above in that the licensee does not have a currebt roster which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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