<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700105
Report Date: 02/03/2022
Date Signed: 02/03/2022 07:13:36 PM

Document Has Been Signed on 02/03/2022 07:13 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197700105
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 23CENSUS: 7DATE:
02/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:37 PM
MET WITH:Maria Deysi RodriguezTIME COMPLETED:
07:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/3/22 LPA conducted a subsequent inspection, during the investigation LPA interviewed staff present. Staff Florencia Cox Calbac is not fingerprint cleared. LPA observed a staff member, Florencia Cox Calbac on the premises without a fingerprint clearance interacting with the day care children. Mrs. Florencia Cox Calbac has been working at the Family Child Care Home for one year. According to Assistant, staff member was present in Lieu of Licensee due to an emergency. Informed staff she is required to be -fingerprinted and may not return until a fingerprint clearance is granted.
Facility was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. A copy of this licensing report (LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent. A copy of the Acknowledgment of receipt of licensing report (LIC9224) was
provided and must be kept in each child's file. In addition, any child enrolled within the following 12 months must also receive a copy of the Type A Citation.

An exit interview was conducted, a copy of this Report, Appeal Rights, and Notice of Site Visit were provided to Assistant Maria Deysi Rodriguez.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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 02/03/2022 07:13 PM - It Cannot Be Edited


Created By: Isabel Ortega On 02/03/2022 at 05:39 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2022
Section Cited
CCR
102370

1
2
3
4
5
6
7
All adults assisting at the facility or living at the facility must first obtain a fingerprint clearance. A civil penalty of $100.00, per day the person has been present, will be assessed. The first violation is subject to the penalty for up to five days. If there is a subsequent violation in a 12 month period, a civil penalty may be assessed up to 30 days. A civil penalty in the amount of $1,000.00 will be assessed.
1
2
3
4
5
6
7
Fingerprint clearances for Florencia Cox must be obtained immediately. Mrs . Florencia Cox is prohibited from being at the facility until fingerprint clearance from DOJ, FBI, CAIC. Licensee shall submit documentation and fingerprint clearance for all staff to the Palmdale RO immediately and staff is to seise position until cleared.
8
9
10
11
12
13
14
Please see Lic 421B... Criminal record clearance: Florencia Cox was observed supervising day care children and is not fingerprint clearanced. She stated that she has been assisting with the facility for a about a year.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Carissa Bell
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2