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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494524
Report Date: 08/05/2025
Date Signed: 08/05/2025 02:19:40 PM

Document Has Been Signed on 08/05/2025 02:19 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197494524
ADMINISTRATOR/
DIRECTOR:		PEREZ, JOHANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 304-6887
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
08/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Johana Perez - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 08/05/2025 Licensing Program Analyst (LPA) Cristina Castellanos conducted an unannounced Case Management Inspection at the above-mentioned facility for the purpose of ensuring the standards are being met in accordance with California Tittle 22 Regulations and California Health and Safety Codes. Present during today’s inspection were twelve (12) children in care, two adult staff members, Licensee Johana Perez, and licensee’s minor child.

Based on interview and record review, 4 out of 12 children’s files were incomplete/not available; Three (3) children’s files only had Immunization Records on file and one (1) child’s file (C2) was not available for review.

LPA reviewed and provided Licensee Perez the LIC 311D - Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, & information to be posted and LIC 125 - Entrance Checklist.

There were (2) deficiencies Type B cited during today’s inspection in accordance with the California Code of Regulations, Title 22, Division 12, and Chapter 3. See LIC 9099-D for additional information.

An exit interview was conducted, and the report was reviewed with Licensee Perez. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of these documents. Upon receipt of this report, the Licensee shall post the Notice of Site Visit. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in an immediate $100 civil penalty.
NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Cristina Castellanos
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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 08/05/2025 02:19 PM - It Cannot Be Edited


Created By: Cristina Castellanos On 08/05/2025 at 01:19 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
102419(d)(1)

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Admissions Procedures & Parental & Authorized Representative's Rights 102419 (d)(1) At the time of acceptance of each child into care, the licensee shall provide the child's parent… (1)The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A …The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).
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Licensee agrees to have the children files completed as well as an updated Chidren's Roster LIC9040.
Licensee will submit proof of completion to LPA via email by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above: 4 out of 12 children’s files were incomplete/not available, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
08/12/2025
Section Cited
CCR102421(b)

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Child's Records 102421(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as requiredin Section 102417(g)(7)."
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Licensee agrees to have the children files completed. Licensee will submit proof of completion to LPA via email by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above: 4 out of 12 children’s files were incomplete/not available, 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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Cristina Castellanos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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