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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493072
Report Date: 04/24/2024
Date Signed: 04/26/2024 09:56:10 AM

Document Has Been Signed on 04/26/2024 09:56 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:PACLEB FAMILY CHILD CAREFACILITY NUMBER:
197493072
ADMINISTRATOR/
DIRECTOR:		PACLEB, BYANKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 500-2960
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
04/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Byanka PaclebTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 04/24/24 Licensing Program Analyst (LPA) Ranita Richmond conducted an unannounced visit for case management at the above mentioned facility. LPA was greeted by teacher Jennifer. At approximately 1:20pm licensee Byanka Pacleb joined.

LPA Richmond observed 13 children in care, being supervised and cared for appropriately by two staff plus licensee.

LPA Richmond toured the home inside and outside for a Health and Safety inspection. The home is neat and clean with heating and ventilation for safety and comfort.

During visit LPA requested and was provided the following documents: children’s roster,files, sign in sheets for children and staff for week of 4/22/24-4/24/24.

LPA reviewed 2 children’s files and observed them to be in compliance of and contain current contact information for authorized representatives and/or relatives who can assume responsibility for the child. Files need to be in compliance of missing authorization for medical treatment, signed Parent’s Rights, signed personal rights, health history, and physician's report. No file available for Noah Mena according toTitle 22, Division 12, Chapter 1 Article 06. Continuing Requirements this standard has not been met.

Type B citation is cited.

See LIC 809D,

An exit interview was conducted, a copy of this report was read and provided to Licensee Byanka Pacleb.

Notice of Site Visit was provided and required to be posted for 30 days.


SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 04/26/2024 09:56 AM - It Cannot Be Edited


Created By: Ranita Richmond On 04/24/2024 at 02:25 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: PACLEB FAMILY CHILD CARE
FACILITY NUMBER: 197493072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
102421(a)

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102421 Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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Licensee will update all required documents by having parents complete and sign all documents and return to licensee to keep in each child's file. Licensee will submit proof of completion to LPA via email.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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