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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017254
Report Date: 06/21/2024
Date Signed: 06/21/2024 01:28:50 PM

Document Has Been Signed on 06/21/2024 01:28 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:TOMAS FAMILY CHILD CAREFACILITY NUMBER:
198017254
ADMINISTRATOR/
DIRECTOR:		TOMAS, FRANCISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
5629274853
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 4DATE:
06/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Francis TomasTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analysts (LPAs), T. Tran and A. Carter observed the following deficiencies:

During children and adults records reviewed, licensee and her employee failed to provide immunization records and C1 missing enrollment document.

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

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the facility representative, Francis Tomas.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 06/21/2024 01:28 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 06/21/2024 at 11:16 AM
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: TOMAS FAMILY CHILD CARE
FACILITY NUMBER: 198017254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
HSC
1597.622(a)(1)

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This requirement is not met as evidenced by based on record review facility failed to obtain immunization record against influenza, pertussis, and measles for licensee and her employee, which poses a potential health and safety risk to children in care.

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Licensee agrees to complete the required immunization records for herself and her employee then email to LPA by or before 7/19/24 in order to clear this citation.
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Type B
07/19/2024
Section Cited
CCR102421(a)

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This requirement is not met as evidenced by
based on record review facility failed to have C1 record, which poses a potential health and safety risk to children in care.
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Licensee willl have C1's parent to complete the enrollement record prior to enroll in the home then submit to LPA by email on or before 7/19/24 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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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