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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841268
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:50:37 PM

Document Has Been Signed on 08/10/2023 03:50 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:TEMPLE LEARNING CENTERFACILITY NUMBER:
364841268
ADMINISTRATOR:DAVIS, LINDAFACILITY TYPE:
850
ADDRESS:1583 UNION STREETTELEPHONE:
9098854695
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92411
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 17DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Linda Davis Preschool DirectorTIME COMPLETED:
04:00 PM
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On 08/10/2023 at time listed above Licensing Program Analysts (LPAs) Steven Montoya and Justin Giese arrived at the facility unannounced to conduct a 1 year required annual inspection. LPAs were granted entry by Preschool Director, Linda Davis. LPAs toured the facility, inside and out, reviewed records, and observed and/or discussed the following: LPAs observed 17 children in care.

Normal days and hours of operation: Monday - Friday 07:00am to 06:00pm

· A review of the staff records and review of a sampling of children's records were conducted as part of this evaluation.

The inspection consisted of reviews of the following domains:
· Food Service
· Reporting Requirements
· Physical Plant
· Care and Supervision
· Children Records
· Staff Records
· Staffing Ratio and Capacity
· Personal Rights

The inspection found the facility to be in compliance in these domains, except were noted on LIC809D.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268
VISIT DATE: 08/10/2023
NARRATIVE
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The licensee was asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization
5. LIC 308 Designation of Administrative Responsibility
· The following items have been posted and are updated where necessary: License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148) Parent’s Rights Poster (PUB393), Personal Rights (LIC613A); Child Car Seat Law, Menu
· The facility is not operating within the terms of the license. LPA observed one school age child in attendance (see LIC809D)
· Ratios were not met during this inspection.
· Appropriate supervision was provided during this inspection
· Rooms are equipped with age appropriate furniture and equipment in good condition
· Napping equipment is sufficient for capacity and meets licensing requirements
· Rooms are clean and free of hazards
· No weapons stored at the facility
· There are no bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Medications are stored where inaccessible to children. Hazards are stored where inaccessible to children. Toxins are locked
· Facility has two toileting areas. One was observed to be safe, sanitary and in operating condition. At 10:38am the second was observed to be in disrepair. Please refer to LIC809D.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268
VISIT DATE: 08/10/2023
NARRATIVE
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Measures are taken to keep the facility free of flies, other insects and rodents
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins-have tight-fitting covers and in good repair
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request
· Uncontaminated drinking water shall be readily available both indoors and out and provided by filtered water bottles. cups made available if needed for indoor and outdoor use
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall: grass and wood chips. At 10:46am LPAs observed outdoor play surface not maintained. (See LIC 809D) .
· Sign in/Sign out record was reviewed and does not meet regulation requirements. (See LIC 809D)
· A Staff member is present with current Pediatric CPR/First Aid which expires on 5-20-2025
· Opening and closing staff member’s CPR/First Aid expires on 05-20-2025
· Director completed Health and Safety Training and is on file
· Staff qualifications were reviewed – all staff meet educational requirements and requirements for performing assigned tasks
· Staff have received on the job training for house keeping, sanitation and universal health precautions
Licensee was informed of the Department has inspection authority per Health and Safety Codes sections: 1596.852, 1596.853 and 1596.8535.

Licensee was informed of Unusual Incident Reporting email
UnusualIncidentReportsDO09@dss.ca.gov

· Required records reviewed for children had missing medical assessment, immunizations and consent for medical treatment forms. (See LIC809D)
· Documentation of fire & earthquake drills to be conducted every six months: At 11:37am LPAs observed last document drill log to be on 09/12/2022. (please see LIC809D)
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268
VISIT DATE: 08/10/2023
NARRATIVE
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Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

CCC did not comple testing prior to their deadline. LPAs did not observe any drinking fixtures in the facility. Facility provides bottled drinking water to children in care. Facility will explore potential testing or apply for exemption.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268
VISIT DATE: 08/10/2023
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience.

If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov

For additional information regarding the inspection and its tools and methods, please visit the Program website at:
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process


A notice of site visit was given and must remain posted for 30 days

THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC809D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT.

Exit interview conducted and report was reviewed with Preschool Director, Linda Davis.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Steven Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 08/10/2023 03:50 PM - It Cannot Be Edited


Created By: Steven Montoya On 08/10/2023 at 01:21 PM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed one of the childrens restrooms to be in disrepair. LPAs observed standing water on floor, water damage to walls and ceiling, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Director will submit a written plan of action or work oder for repairs to the restroom to LPA by 8-11-2023. Director agrees to submit a plan of action/work order to the department for immediate repairs to bathroom #2 no later than 8-11-2023. Licensee can email LPA at steven.montoya@dss.ca.gov
Type A
Section Cited
CCR
101161(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations and interview, While taking Census of children present, LPAs observed a school age child. LPAs identified the child's age to exceed the terms of the Facility's preschool License, ages 2-5 years old. This is an immediate risk to the health and safety of children in care.
POC Due Date: 08/11/2023
Plan of Correction
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Director understands the importance of this regulation and will submit a written plan outlining the understanding of the terms of current daycare license. Director will have all staff members sign this plan in agreement to adhere to the terms and age limits of daycare license. Director will submit this written plan to LPA within 24 hours. Plan of correction date for this correction is set on 08/11/2023. Licensee can email LPA at steven.montoya@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 08/10/2023 03:50 PM - It Cannot Be Edited


Created By: Steven Montoya On 08/10/2023 at 01:21 PM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Facility did not have current disaster drill log to review at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Director will conduct disaster drill and submit drill log via email to LPA (steven.montoya@dss.ca.gov) by 8-17-2023.
Type B
Section Cited
CCR
101238.2(d)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee did not comply with the section cited above. Facility did not maintain outdoor play space LPAs observed weeds and sparce arears of wood chips around play structure and was informed children do not currently use outdoor space, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee will properly maintain outdoor play surface area by removing weeds, dispurse woodchips over sparce areass to allow children to utelize play area. Director will provide photos of outdoor play surface area to LPA Steven Montoya via email. steven.montoya@dss.ca.gov by 8-17-2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 08/10/2023 03:50 PM - It Cannot Be Edited


Created By: Steven Montoya On 08/10/2023 at 01:21 PM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the facility did not comply with the section cited above. Facility did not have current written medical assessments in 4 out 5 children records reviewed at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Director will obtain medical assessments for 4 children's files mentioned above to stay in compliance with regulation. Director will send a copy of medical assessments to LPA via email (steven.montoya@dss.ca.gov) by 8-31-2023.
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the facility did not comply with the section cited above. Facility did not have current immunization records in 5 out of 5 children's records at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Director will obtain immunization records for all 5 children's records reviewed as mentioned above and submit records to LPA via email (steven.montoya@dss.ca.gov) by 8-31-2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 08/10/2023 03:50 PM - It Cannot Be Edited


Created By: Steven Montoya On 08/10/2023 at 01:21 PM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the facility did not comply with the section cited above. Facility did not have written consent for medical treatment (LIC627) in 5 out 5 children records reviewed at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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2
3
4
Director will obtain consent for medical treatment (LIC627) for the 5 children files mentioned above to stay in compliance with regulation. Director will send a copies of (LIC627) to LPA via email (steven.montoya@dss.ca.gov) by 8-17-2023.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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. LPAs observed current sing-in/sign-out log without authorized representative signatures, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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2
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Director agrees to have authorized represetnative sign child(ren) in/out using full signatures and in/out times. Director agrees to provide LPA with 5 days of updated sign-in/sign-out sheets via email (steven.montoya@dss.ca.gov) by 8-17-2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 08/10/2023 03:50 PM - It Cannot Be Edited


Created By: Steven Montoya On 08/10/2023 at 01:27 PM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TEMPLE LEARNING CENTER
FACILITY NUMBER: 364841268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.841
1596.841 Current roster of children provided care in facility required.
Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Facility did not have current roster of enrolled children available to review at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
1
2
3
4
Director agrees to complete facility roster for enrolled children and submit to LPA via email on or before 8-17-2023.
Steven.montoya@dss.ca.gov.
Section Cited
Deficient Practice Statement
1
2
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.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Steven Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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