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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494930
Report Date: 11/15/2021
Date Signed: 11/15/2021 01:00:32 PM

Document Has Been Signed on 11/15/2021 01:00 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GREEN FAMILY CHILD CAREFACILITY NUMBER:
197494930
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:MONICA GREENTIME COMPLETED:
01:10 PM
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On 11/15/2021 at 11:45 AM Licensing Program Analyst (LPA) Loyce Phillips conducted an announced Pre Licensing inspection with applicant Monica Green. Today's inspection is a follow up to the Pre-Licensing inspection conducted on 11/3/2021.

During the pre-licensing inspection conducted on 11/3/2021 the following corrections were needed:
- Fire place shall be made inaccessible.
- Kitchen made inaccessible.
- Right side of home and left side of garage made inaccessible.
- Bedrooms #1 and #2 made inaccessible.

During today's inspection the following corrections were observed and completed:


- Fire place is made inaccessible by a safety gate.
- Kitchen is made inaccessible by a safety gate.
- The right side of home and left side of garage is made inaccessible by a safety gate.
- Bedrooms #1 and #2 is made inaccessible by door chain locks.

Applicant is approved for license pending managers approval.

An exit interview was conducted and a copy of this report was provided to the applicant, Monica Green.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Loyce Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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