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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300460
Report Date: 04/14/2022
Date Signed: 04/15/2022 07:52:27 AM

Document Has Been Signed on 04/15/2022 07:52 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:URBINA, JESSIE & IRELIFACILITY NUMBER:
304300460
ADMINISTRATOR:URBINA, JESSIE & IRELIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 229-4847
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ireli Urbina, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tran conducted a case management inspection and met with Licensee Ireli Urbina. The purpose of the visit was to conduct an Annual Inspection. Upon arrival, Licensee Ireli Urbina informed LPA Tran that the day care is currently inactive.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

LPA Tran observed Licensee, her mother Josefina Carranza and sister Maria Carranza and two of Licensee's children in the home.

LPA Tran provided LIC 9211 for Licensee to request to place the License on Inactive Status and Licensee completed the form during the visit.

There was no deficiency cited during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Ireli Urbina.


(End of Report)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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