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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011719
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:30:08 PM

Document Has Been Signed on 08/25/2021 01:30 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:RANGEL FAMILY CHILD CAREFACILITY NUMBER:
198011719
ADMINISTRATOR:RANGEL, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 291-4910
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Evangelina Rangel, LicenseeTIME COMPLETED:
01:40 PM
NARRATIVE
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About 11:00 AM, While investigating for a complaint, Licensing Program Analyst (LPA), T. Tran observed the following deficiency:

Based on record review and interview conducted, licensee admitted on 02/18/2020, licensee received C1 (LIC 811) without any enrollment record until 03/01/2020. In addition, on 02/25/2020, C1 got injured on the lower lip while in care and licensee admitted that she failed to report this incident to the licensing department.

Licensee was cited for type B deficiencies. See Facility Evaluation Report LIC 809D for deficiency cited.

A copy of this report was provided to the licensee and an exit interview was conducted.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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Document Has Been Signed on 08/25/2021 01:30 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 08/25/2021 at 12:20 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RANGEL FAMILY CHILD CARE
FACILITY NUMBER: 198011719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited
CCR
102421

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Child's Records
This requirement is not met as evidenced by based on record review and interview licensee failed to obtain C1 enrollment record which poses a potential health and safety risk to children in care.
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Licensee will submit a written statement acknowledging that licensee must obtain and review all new children enrollment records prior to accept children in care then submit to the Department no later than 09/17/2021 in order to clear this citation.
Type B
09/17/2021
Section Cited
CCR
102416.2

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Reporting Requirements
This requirement is not met as evidenced by based on record review and interview licensee failed to report an incident occurred 02/25/2020, C1 got injured on the lower lip while in care which poses a potential health and safety risk to children in care.
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Licensee will submit a written statement acknowledging that licensee must obtain and review all new children enrollment records prior to accept children in care then submit to the Department no later than 09/17/2021 in order to clear this citation.

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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:Trevino Cochran
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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