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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400654
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:56:04 PM

Document Has Been Signed on 03/13/2024 03:56 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:AMAYA FAMILY CHILD CAREFACILITY NUMBER:
198400654
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Licensee - Jose David AmayaTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) R. Derraco and C. Kam conducted an unannounced case management visit to the above mentioned facility on 03/13/24 at 3:20 PM. LPA was met by licensee, Jose David Amaya who guided analyst on a tour of the home. LPAs observed 2 additional adults and 4 children in care during inspection. The home was observed to be clean and free of defects.

The purpose of this visit is to issue a citation involving an uncleared adult living in the home. Both licensee and assistant confirm that S4 has been living in the home for approximately 8 months. Licensee states that S4 is currently at work and returns home approximately 7:00 PM. Per review of Livescan form, incorrect information was provided when fingerprints were taken on 03/09/23. LPAs advised licensee that a citation under California Code of Regulation (CCR) Section 102370(d)(1) will be issued.

The following deficiency listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiency that is being cited need to be cleared to protect the children’s health & safety

Exit interview conducted, appeal rights provided, and report was reviewed with the licensee Jose David Amaya.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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 03/13/2024 03:56 PM - It Cannot Be Edited


Created By: Randy Derraco On 03/13/2024 at 03:33 PM
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: AMAYA FAMILY CHILD CARE
FACILITY NUMBER: 198400654

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2024
Section Cited
CCR
102370

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102370 Criminal record clearance (d) All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not as evidenced by:
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Licensee states that S4 will obtain criminal record clearance. No children can be cared for while S4 is in the home.
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Based on observation, interview and record review, the licensee did not have S4 obtain background clearance which poses a potential Health, safety and/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:Denise Gibbs
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


LIC809 (FAS) - (06/04)
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