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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019446
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:32:49 PM

Document Has Been Signed on 05/10/2022 02:32 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CUERVO & ESCAMILLA FAMILY CHILD CAREFACILITY NUMBER:
198019446
ADMINISTRATOR:G. CUERVO & L. ESCAMILLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 397-4038
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Lorena Valentina Escamilla, LicenseeTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mireya Garcia conducted an unannounced case management inspection at the above facility due to deficiencies observed. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with Licensee, Lorena Valentina Escamilla who guided LPA on a tour of the facility. Also present was Licensee’s assistant. Licensee Guillermo Cuervo later arrived during this inspection. Census was taken.


During a walk-through of the facility, at 8:38a.m.,LPA Garcia observed that resident Nancy Sanchez is not fingerprint cleared and associated to the facility. LPA determined through Licensee disclosure and verification of the Licensing Information System (LIS) that resident is not fingerprint cleared. Licensee stated that Nancy Sanchez has been residing in the home since 05/06/2022. This poses an immediate risk to the health and safety of children in care. A civil penalty of $500 was assessed on this day.

Report continues on next page 1 of 2.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CUERVO & ESCAMILLA FAMILY CHILD CARE
FACILITY NUMBER: 198019446
VISIT DATE: 05/10/2022
NARRATIVE
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A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224 English/Spanish) Forms during this visit.

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


Exit interview conducted and report was reviewed with facility representative, Lorena Valentina Escamilla.

Report ends here page 2 of 2
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/10/2022 02:32 PM - It Cannot Be Edited


Created By: Mireya Garcia On 05/10/2022 at 12:51 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CUERVO & ESCAMILLA FAMILY CHILD CARE
FACILITY NUMBER: 198019446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
102370(d)(1)

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102370- Criminal Record Clearance: (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department....This requirement is not met as evidenced by:
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During LPAs visit resident Nancy Sanchez left the facility, per Licensee Lorena Valentina she will be in compliance by having resident fingerprinted and resident will not return to the home until fingerprint clearance is granted. A LIC 855 written Declaration was obtained from Licensee.
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Based on LPA observation and Licensee L. Valentina disclosure that resident Nancy Sanchez is not fingerprint cleared and/or associated to the facility. LPA determined through the Licensing Information System (LIS) that resident is not fingerprint cleared. This poses an immediate health and safety risk to children in care.
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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2022 02:32 PM - It Cannot Be Edited


Created By: Mireya Garcia On 05/10/2022 at 01:13 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CUERVO & ESCAMILLA FAMILY CHILD CARE
FACILITY NUMBER: 198019446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2022
Section Cited
CCR
102416.2(a)(2)

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102416.2-Reporting Requirements:(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in and out of the home .. This requirement is not met as evidenced by:
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Per Licensee L. Valentina, she will update LIC 279 FCC Application & complete LIC 279B current children in the home and will submit forms to the Department no later than 05/17/2022.
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Based on LPA's observation and Licensee's disclosure 2 new adults and 2 children have moved into the home temporarily since March of 2022, and Licensee's did not report this to the Department.This poses a potential health and safety risk to children in care.
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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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