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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015336
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:12:29 PM

Document Has Been Signed on 10/09/2023 02:12 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN SPRINGS CHILD DEVELOPMENT CENTER, RM. 29FACILITY NUMBER:
198015336
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:245 S. BALLENA DR.TELEPHONE:
(909) 806-2392
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 15TOTAL ENROLLED CHILDREN: 29CENSUS: 8DATE:
10/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Teresita Van Gordon, Erika Mendez & Bobby GuerreroTIME COMPLETED:
01:05 PM
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Case management inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. The purpose of the visit is to follow up on the incident that was reported to the Department on 9/12/23. LPA arrived to the Golden Springs Elementary School office at 11:45am, and was directed to Room #29. LPA arrived to room #29 at 11:48am. LPA met with Substitute teacher Teresita Van Gordon & Erika Mendez. The purpose of the visit was announced. LPA observed 8 children in care with 2 staff. During the visit, substitute teacher contacted their supervisor to come to the facility to assist. Associate Director, Bobby Guerrero arrived at 12:26pm to assist.

It was reported that a staff member reported that they observed another staff member violated children's personal rights on different occasions but staff does not have dates or time of incidents.

During the visit, interviews were conducted with children and Associate Director.

No deficiency cited at this time.

An exit interview conducted with Associate Director, Bobby Guerrero. Notice of Site Visit Form provided and shall be posted for 30 days.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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