<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843597
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:48:27 PM

Document Has Been Signed on 03/11/2022 03:48 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:QUEVEDO FAMILY CHILD CAREFACILITY NUMBER:
334843597
ADMINISTRATOR:IVE QUEVEDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 902-1473
CITY:COACHELLASTATE: CAZIP CODE:
92236
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Ive QuevedoTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this date, Licensing Program Analysts (LPAs) Ana Noble and James Wilkerson conducted a case management visit as a result of a complaint investigation. During the course of the complaint investigation, it was discovered that the facility failed to report an incident that occurred involving children in care, Child #1 and Child #2, which Licensee faile to report to the Department. Additionally, Licensee adult brother moved into the home according to Licensee in September 2021, who has not obtain a criminal record clearance with the Department.

See LIC 809D for deficiency cited.

An exit interview was conducted, appeal rights were given and discussed, and a copy of this report and Notice of Site Visit was provided to Licensee. Licensee was advised that the Notice of Site Visit must be posted in a prominent location for the next 30 days.

A copy of this report must be made available to the public for 3 years.

SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 3
Document Has Been Signed on 03/11/2022 03:48 PM - It Cannot Be Edited


Created By: Ana Noble On 03/11/2022 at 01:51 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: QUEVEDO FAMILY CHILD CARE
FACILITY NUMBER: 334843597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2022
Section Cited
CCR
102370(a)

1
2
3
4
5
6
7
Criminal Record Clearance. Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. This requirement was not met by evidence by: Based on Licensee own admission, Licensee's adult brother moved into the
1
2
3
4
5
6
7
Licensee agreed to have Adult #1, livescan on Monday, 3/7/2022 and until Adult #1 can be cleared Adult #1 will move out, Liensee will provide address where Adult #1 will reside until clearance can be obtained. Licensee will submit this plan and information in a written statement to the Department by 3/12/2022.
8
9
10
11
12
13
14
home September 2021, and failed to obtain a criminal record clearance. This is an immediate health and safety risk to children in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Hudak
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/11/2022 03:48 PM - It Cannot Be Edited


Created By: Ana Noble On 03/11/2022 at 02:54 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: QUEVEDO FAMILY CHILD CARE
FACILITY NUMBER: 334843597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
CCR
102426.2(a)

1
2
3
4
5
6
7
Reporting Requirements. 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). This requirement was not met by evidence of. Licensee failed to report incident disclosed to her in February involving children in care that
1
2
3
4
5
6
7
Licensee agrees to submit Unusual/Incident Report, LIC624 regarding incident disclosed to Licensee involving children in care in February 2022. Submit this report to the Department by 3/17/2022.
8
9
10
11
12
13
14
required reporting to the Department. This is a potential risk to health and safety of children.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Hudak
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3