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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334818751
Report Date: 12/06/2022
Date Signed: 12/06/2022 04:17:54 PM

Document Has Been Signed on 12/06/2022 04:17 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
334818751
ADMINISTRATOR:NORMA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 378-8372
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
12/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Angelina PerezTIME COMPLETED:
04:30 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct a Case Management visit. Present during the visit were – Ms. Angelina Perez, Sylvia Perez, Alfred Olmedo.

Licensee was not present at the facility, Facility Representative stated that Licensee was at the court. LPA requested Facility Representative for the Facility Roster (LIC 9040). S1 stated that the door to the office is locked, and they do not have the keys to the office. S1 was able to obtain the roster from the office dating back to 2008. Facility did not have an updated current roster present for the department to review. LPA spoke with Licensee on the phone and requested Licensee to update the LIC 9040 (roster) and email a copy to the department by 8 AM on 12/07/22. Licensee agreed to do so.

LPA requested for the 8 files of the children present. S1 gave LPA 6 files and stated the 7th child (C7) only started today 12/06/22 and the parent will be dropping off the documents during pick up. S1 also stated that the 8th child was temporarily dropped off for the day. LPA verified the names of the other 6 children, and it was noted that the 3 files out of the 6 were not of the children present at the facility. LPA requested facility representative or the missing 3 files.

See LIC 809D for deficiencies.

An exit interview was conducted, and this report was reviewed with License Norma Perez. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 04:17 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 12/06/2022 at 03:41 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 334818751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2022
Section Cited
CCR
102417 (g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
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>>>present at the facility for the department to reveiw which poses a potential health, safety or personal rights risk to persons in care.
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Based on record review, the licensee did not comply with the section cited above in having an updated Roster >>>
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Licensee agrees to update LIC 9040 and submit to the department by the POC due date.
Type B
12/07/2022
Section Cited
CCR102421(a)

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102421 (a)(b)(c)(e)The licensee shall maintain, in each child's record, the signed and dated notice form required
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>>>present at the facility for the department to reveiw which poses a potential health, safety or personal rights risk to persons in care.
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Based on record review, the licensee did not comply with the section cited above in having all required forms for C2, C3, C7, and C8 >>>
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Licensee agrees to obtain all required forms for the children (C2, C3, C7, and C8) and submit to the department by the POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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