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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844235
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:24:30 PM

Document Has Been Signed on 09/17/2021 01:24 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:FLORES FAMILY CHILD CAREFACILITY NUMBER:
334844235
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cindy Flores-LicenseeTIME COMPLETED:
01:30 PM
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On 9/17/2021 at 12:30 PM, Licensing Program Analyst (LPA) Andrea Taylor conducted an inspection visit with Licensee, Cindy Flores..

A case management inspection is being conducted in response to the receipt of a self-reported unusual
incident report (UIR) from the facility. The UIR was received by the licensing agency on 8/4/21.
The incident occurred on 8/3/21. The incident reported a child retaliated against another child by pushing the child. The child fell landing on their arm. The Licensee was near the children and visually observed children, but was unable to reach the children in time to prevent child from getting pushed or falling.
License notified guardian immediately. Child was taken to the doctor and diagnosed with a small fracture on the arm.

No deficiencies were cited today.

An exit interview was conducted.
The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days.
Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent
to the door.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Andrea Taylor
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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