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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020326
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:43:30 AM

Document Has Been Signed on 10/03/2024 10:43 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CANCHOLA & GUILLEN FAMILY CHILD CAREFACILITY NUMBER:
198020326
ADMINISTRATOR/
DIRECTOR:		J CANCHOLA & G. GUILLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 802-6239
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 14TOTAL ENROLLED CHILDREN: 23CENSUS: 3DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Gerardo GuillenTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Saul Valenzuela conducted an unannounced Case Management – Other inspection. LPA met with Licensee, Gerardo Guillen to whom the reason for the visit was explained. Licensee guided LPA on a tour of the facility. Census was taken. There were 2 staff present caring for 3 children. The facility was observed to be operating within the license capacity limitations.

During the inspection conducted on 10/3/2024, LPA amended the licensing report dated 9/18/24, and cited Reporting Requirements due to Licensee not reporting an Unusual Incident Report that occurred on 5/14/2024. LPA discussed the Reporting Requirements with Licensee. LPA provided Licensee with the Monterey Park Regional Office Incident Reports email to ensure that reporting requirements are being met.

LPA cleared deficiency on this date for 1 Type A deficiency that were cited on 9/18/2024- LPA issued POC clearance letter during the visit.

Based on the LPA’s records review and interviews, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee, Gerardo Guillen.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Saul Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 10:43 AM - It Cannot Be Edited


Created By: Saul Valenzuela On 10/03/2024 at 10:05 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CANCHOLA & GUILLEN FAMILY CHILD CARE
FACILITY NUMBER: 198020326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
102416.2(a)

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102416.2 Reporting Requirements
(a) The licensee shall report the following information the Department by telephone ... within the Department's next business day...(8am to 5pm).
This requirement is not met as evidenced by:
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Per Licensee they will provide LPA the LIC 624 Unusual Incident Report via email and states that they will review the Reporting Requirement regulations
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Based on interview and record review, the licensee did not comply with the section cited above that Licensee did not report the Unusual Incident Report that occurred on 5/14/2024 within the next business day, which posed a potential health, safety or personal rights risk to persons in care.
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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Saul Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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