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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840301
Report Date: 07/17/2025
Date Signed: 07/17/2025 11:29:15 AM

Document Has Been Signed on 07/17/2025 11:29 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BOUCHEY FAMILY CHILD CAREFACILITY NUMBER:
364840301
ADMINISTRATOR/
DIRECTOR:		BOUCHEY, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 954-4446
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
07/17/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Stephanie Bouchey, Licensee TIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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On 07/17/2025, Licensing Program Analyst (LPA) Justeene Tamayo conducted an unannounced Annual Inspection. The LPA disclosed the purpose of the inspection and was granted entry by assistant #1. Upon entry to the home LPA observed 8 day care children in care with assistant #1. Licensee arrived to the facility shortly after.

Upon walk through, LPA observed a total of 8 day care children (3 infants, 2 preschool age, and 3 school age children) present only with assistant #1. Licensee was informed she can have no more than 2 infants, one child enrolled in kindergarten, and one child at least age 6 years of age when caring for a total of 8 day care children, which poses an immediate health and safety risk to day care children in care. Facility has been cited a Type A citation. Please see LIC809-D for deficiency page.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

This is a two-story-family home. There is a living room, dining room, kitchen, five bedrooms, three restrooms, a back yard, and an attached garage. Main care is provided in Room #1 referred to as the childcare play area and the living room and dining room. The off-limits areas are the bedrooms #2, #3, #4 and #5, the two restrooms which are located on the second floor (LPA observed a child safety gate at the bottom of the stairs), and the attached garage (maintained key locked).

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
NARRATIVE
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 Children utilize the restroom next to bedroom #1 by the attached garage. Children utilize the back yard for outdoor play. The back yard is fenced all around.

Licensee provides children enrolled with breakfast, morning snack, lunch, afternoon snack and dinner as needed.

The operational childcare hours are Monday through Sunday varied up to 23 hours depending on parent’s need. Licensee provides over night care and transportation(a valid Driver's license and auto insurance observed.)



The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Knives, medication, cleaning supplies and chemicals are kept inaccessible to children (magnetic lock observed).
There are educational age-appropriate toys and equipment on the premises.

The First Aid kit with a temperature thermometer was observed and complete. The required fire extinguisher (3A40BC) is reading in green. A dual Smoke and carbon monoxide detector were tested and found to be in operating condition.

Licensee had all the required documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148).

During file review of children's files, child #7 and child #8 were missing their proof of immunization documentation, which poses a potential health and safety risk to day care children in care. Facility has been cited a Type B Citation. Please see LIC809-D for deficiency page.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
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The licensee maintains proof of immunization against pertussis (TDAP), measles (MMR), TB and influenza, however, Assistant #1 did not have proof of pertussis, measles, and influenza, which poses a potential risk to day care children in care. Please see LIC809-D for deficiency page.

Licensee’s Pediatric CPR/First Aid training certificate expires on 04/14/2026. However, upon arrival, Licensee left assistant #1 alone with day care children with expired CPR/First Aid, expired on 07/11/2025, which poses a potential health and safety risk to day care children in care. Facility has been cited a Type B Citation. Please see LIC809-D for deficiency page.

Licensee's Mandated Reporter training expires on 04/13/2026. Child Care Provider Mandated Reporter training (AB1207) is required to be renewed every two-years.

Emergency drills shall be conducted every six months, Last Fire/Disaster drill was completed on 05/12/2025.

The Licensee was reminded to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. Licensee was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.

The following was also discussed with the licensee/The following items are zero tolerance by Licensing:



1. Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
NARRATIVE
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4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be evaluated.

7. The fire extinguisher Type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 5 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
NARRATIVE
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12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunization.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 6 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
NARRATIVE
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Licensee's facility child roster shall be current and maintained up to date.

The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category are permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty. LPA observed a baby bouncer at the facility – infant was not observed utilizing bouncer. Removed during inspection to an off-limits area(technical Violation given).

Safe Sleep regulations (under 24 months) were discussed with Licensee and referred to the CCL web site for additional information and PINS. Infants under 2 years of age shall have the 15-minute checks logs completed during nap time. Safe sleep logs were not able to provide a notebook was demonstrated with nap time start time. (type B citation was issued). All infants under one year of age shall have the LIC9227 sleep plan completed by parent until infant master’s developmental stage of rolling over on their own. Licensee was not able to provide the LIC9227 forms on file for infants enrolled 0-12 months (type B citation was issued).

The licensee is aware all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 7 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 07/17/2025
NARRATIVE
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MyChildCarePlan.org-Family Child Care Homes Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Megan’s Law - Family Child Care Homes During the exit interview, according to licensee there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Child Care Advocates:


To sign up for our Quarterly Updates please email the Child Care Advocates at chilcareadvocatesprogram@dss.ca.gov & (916) 654-154.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000.

Facility has been cited one Type A Citation and 3 Type B Citations and 2 Technical violations during this visit.

An exit interview was conducted, a copy of this Report, a Notice of Site visit and Appeal rights were provided and discussed with licensee.

All licensing reports are recommended to keep for 3 years, and the Notice of Site visit is to be posted visible to parents for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 07/17/2025 11:29 AM - It Cannot Be Edited


Created By: Justeene Tamayo On 07/17/2025 at 11:13 AM
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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(3)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (3) More than six and up to eight children, without an additional adult attendant, only if the criteria in
Section 1597.44 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above. LPA observed a total of 8 children (3 infants, 3 school age, and 2 preschool age children), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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LPA will conduct a Plan of Correction visit for Type A citation cited.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Justeene Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 07/17/2025 11:29 AM - It Cannot Be Edited


Created By: Justeene Tamayo On 07/17/2025 at 11:13 AM
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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Assistant #1 CPR/FIrst aid was expired on 07/11/2025, and was left with the day care children alone, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee will send proof of assistant #1 CPR/First Aid no later than 08/18/25 via email.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Assistant #1 did not have proof of pertussis, measles, and influenza, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee will send assistant #1 proof of pertussis, measles, and influenza no later than 07/31/2025 via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Justeene Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 07/17/2025 11:29 AM - It Cannot Be Edited


Created By: Justeene Tamayo On 07/17/2025 at 11:13 AM
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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Childrent #7-8 did not have proof of immunizations,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee will submit proof of immunizatins for child #7 and child #8 no later than 07/31/25 via email.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Justeene Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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