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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017825
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:55:58 PM

Document Has Been Signed on 04/14/2022 03:55 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:HENRIQUEZ FAMILY CHILD CAREFACILITY NUMBER:
198017825
ADMINISTRATOR:HENRIQUEZ, GENESISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 597-5368
CITY:LONG BEACH, CA.STATE: CAZIP CODE:
90815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Genesis HenriquezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Required 1 Year inspection. LPA met with Licensee Genesis Henriquez who guided LPA on a tour of the facility. The purpose of today's inspection is to verify that items from a previous inspection was cleared. The Licensee was caring for five children.

The following items are cleared: The Licensee removed the propane grill from the outdoor play area and completed the Mandated Reporter Training on March 24, 2022

All items are cleared and there are no citations.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. This report along with a copy of the appeal rights was provided. Exit interview was conducted with Licensee Henriquez.


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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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