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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020274
Report Date: 06/18/2021
Date Signed: 06/18/2021 04:45:45 PM

Document Has Been Signed on 06/18/2021 04:45 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:APPLEGATE FAMILY CHILD CAREFACILITY NUMBER:
198020274
ADMINISTRATOR:REBECCA APPLEGATEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 254-6957
CITY:GLENDALESTATE: CAZIP CODE:
91208
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
06/18/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rebecca Applegate, LicenseeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Thelma Razo conducted a Case Management - Licensee Initiated and met with Licensee Rebecca Applegate. LPA stated the purpose of the visit and together, toured the facility to include one bedroom which is being added as day care area. LPA observed there is one adult family member and two minors residing in this home. There is one child from another household during this inspection.

All areas identified on the Facility Sketch were inspected to include the following:
· Childcare areas: Day care room, one bedroom, dinning room, family room, kitchen, two bathrooms, front yard, backyard.
· Off limit areas: Licensee's master bedroom, one bedroom, garage and concrete area near the outdoor grill.
All areas used by children were inspected for safety, comfort, cleanliness, telephone, ventilation and heating (central).

An updated facility sketch was obtained today to designate concrete area where the outdoor grill is located as off limit. There are no citations being issued at the time of inspection under California Code of Regulations, Title 22 Division 12.

The Notice of Site Visit (LIC 9213) was given – 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.

Exit interview was conducted with Licensee. Appeal rights explained & provided together with the Facility Evaluation Report.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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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