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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020198
Report Date: 04/26/2021
Date Signed: 04/27/2021 11:02:05 AM

Document Has Been Signed on 04/27/2021 11:02 AM - 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:CLARK FAMILY CHILD CAREFACILITY NUMBER:
198020198
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/26/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Brianna Clark TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Judy Mora contacted the facility via telephone for a Case Mangement Inspection due to COVID-19 and pre-cautionary measures. The reason for inspection is that the applicant has applied for an increase of capacity. LPA spoke to Brianna Clark, the call was then transferred into a Face Time call. The Fire Department has granted clearance for a maximum capacity of 14 children, fire clearance received on 02/26/21. There were no children present during the inspection.

This is a one story home which consists of 2 bedrooms, 1 bathroom, kitchen, dining room, living room (FIREPLACE: inaccessible), front and backyard (fenced), and detached recreation room/garage. The children use the bathroom, living room, dining room, backyard for play and recreation room. Per licensee, areas off limits to children and parents include: kitchen, bedrooms and garage. There are kiddie gates blocking access to the kitchen. The LPA toured all areas used by children during this visit. There is a fireplace in the recreation room which is also inaccessible. The fire extinguisher was last served on 02/03/21. Smoke and carbon monoxide detectors are in operable condition. Licensee has current Pediatric First Aid & CPR which expires in 03/2023.



At this time, the licensee is in compliance with California Title 22 Regulations. LPA will recommend the increase in capacity as the licensee meets requirements for an increase and the fire clearance was received and granted for 14 children.

An exit phone interview has been conducted with Brianna Clark. A copy of this report has been signed by LPA Mora. This report along with the Appeal Rights will be scanned via e-mail to the Licensee, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature. A hard copy of this report and the Appeal Rights will be mailed out to the Licensee who agrees to sign the bottom of each page of the 809 and return the originals to LPA Mora in-person or via U.S. Mail. The Notice of Site Visit is also being sent via email. Notice of Site Visit must be posted for 30 days. Failure to maintain posting will result in a civil penalty.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2021
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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