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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400128
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:50:30 AM

Document Has Been Signed on 10/06/2022 10:50 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
198400128
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
10/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Martha LopezTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elka Chavez conducted an unannounced Case Management inspection to the above facility, LPA met with Martha Lopez.

At 9:45 AM LPA observed that the licensee did not have a facility roster. This is a potential health and safety risk to children in care.

The following deficiency listed on the attached LIC 809D is being cited in accordance with California Code of Regulations Title 22.

Exit interview was conducted with Licensee, Martha Lopez.



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.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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Document Has Been Signed on 10/06/2022 10:50 AM - It Cannot Be Edited


Created By: Elka Chavez On 10/06/2022 at 10:08 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198400128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
HSC
1596.841

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1596.841 Current roster of children provided care in facility required Each child day care facility shall maintain a current roster of children who are provided care in the facility...This requirement is not met as evidenced by
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Licensee stated that going forward she will make sure to update the roster and follow the LIC 311D provided during prelicensing.
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Based on records review at 9:45 AM licensee did not have a roster which poses a potential rist to Health, Safety or Personal 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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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