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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846156
Report Date: 08/23/2023
Date Signed: 08/23/2023 11:06:04 AM

Document Has Been Signed on 08/23/2023 11:06 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:GREEN FAMILY CHILD CAREFACILITY NUMBER:
364846156
ADMINISTRATOR:GREEN, EBONYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 533-3348
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ebony GreenTIME COMPLETED:
11:15 AM
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On August 23, 2023 Licensing Program Analysts (LPAs) Elyse Jones and Raymond Moorehead arrived at the facility to conduct a Case Management-Other visit. Licensee granted access to the facility. LPA Moorehead conducted a facility tour, census was taken and documentation was collected.

Four children were present during the inspection. Current days and hours of operation are Monday through Friday, from 7:00 AM to 6:00 PM. Licensee confirmed the only individuals residing in the facility are listed on the LIC279 dated 2-22-2023. Licensee also confirmed all individuals working, residing or volunteering at the facility are listed on the Guardian Association Roster and the LIC531 dated 8-22-2023. LPA Jones reviewed the regulation section 102370 Criminial Record Clearance with the Licensee and a copy of the regulation was left with the Licensee during the inspection.

Based on the above, the facility was found to be in compliance with Title 22, at this time. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted. Report was reviewed and a copy of the report was provided to Ebony Green, Licensee.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Raymond Moorehead
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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