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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300586
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:32:21 PM

Document Has Been Signed on 10/17/2023 12:32 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:MCKENZIE FAMILY CHILD CAREFACILITY NUMBER:
336300586
ADMINISTRATOR:MCKENZIE, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 323-7121
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kimberly MckenzieTIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPAs), Sumayya Habeebulla and Amber Shaw, arrived at the facility to conduct a Case Management on this date and met with Licensee Ms. Kimberly McKenzie. LPA informed Licensee that a premise visit was being conducted in order to verify the names of adults living in the home and confirm that a criminal record clearance has been received.

LPA informed Licensee, that an employment inquiry was received by the CCL and LPA was on site to obtain names and pertinent information.


An exit interview was conducted, and a copy was provided this date.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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