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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845491
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:18:05 PM

Document Has Been Signed on 09/14/2023 03:18 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:ALLEN FAMILY CHILD CAREFACILITY NUMBER:
334845491
ADMINISTRATOR:ALLEN,BRIANNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(301) 256-8151
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Brianne AllenTIME COMPLETED:
03:25 PM
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On September 14, 2023 at 2:10 pm, Licensing Program Analyst (LPA) Jessica Rubio arrived unannounced to the facility to conduct a case management visit due to an unusual incident report received for an incident that occurred on 8/9/2023, reporting child (C1) was laying on two foam blocks, while holding another child's (C2) hand when C1 fell off the blocks causing C1's elbow to pop out of the socket and sustain a fracture on their elbow. LPA met with Licensee Brianne Allen and conducted a tour and census of the facility. During the visit, LPA interviewed licensee and C1. Interviews revealed that there were seven children in care with licensee providing care and licensee observed the incident. Licensee consoled and assessed C1 as well as provided C1 an ice pack. C1 was picked up by a family member approximately 10 minutes after the incident occurred. Licensee also contacted C1's parent and informed parent of the incident. LPA determined there are no violations and no deficiencies were cited at this time.

An exit interview was conducted and a copy of this report and LIC 811 (Confidential Names List) was provided to Licensee Brianne Allen. Appeal rights were also provided and a notice of site visit was provided to Licensee. The notice of site visit must remain posted for 30 days.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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