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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844810
Report Date: 04/11/2022
Date Signed: 04/11/2022 01:31:18 PM

Document Has Been Signed on 04/11/2022 01:31 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:MUNOZ FAMILY CHILD CAREFACILITY NUMBER:
334844810
ADMINISTRATOR:MUNOZ,VALERYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 880-7118
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 14TOTAL ENROLLED CHILDREN: 17CENSUS: 7DATE:
04/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Valery MunozTIME COMPLETED:
01:45 PM
NARRATIVE
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On date and time listed above, Licensing Program Analysts (LPAs) Sumayya Habeebulla and Ana Noble arrived at the facility to conduct an annual inspection. During the file reviews it was observed that LIC 9224 - Acknowledgement of Receipt of Licensing Reports for Type A deficiency which was issued on 07/23/21 was not present in files for 6 out of 7 of files reviewed during the inspection.
LIC 9224 - Acknowledgement of Receipt of Licensing Reports for Accusations issued by the department dated 01/10/22 were not on file in 7 out of 7 files reviewed during today's inspection.

See LIC 809D for deficiencies.

An exit interview was conducted, and this report was reviewed with the licensee Valery Munoz. 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: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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 2
Document Has Been Signed on 04/11/2022 01:31 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 04/11/2022 at 12:40 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: MUNOZ FAMILY CHILD CARE
FACILITY NUMBER: 334844810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
HSC
1596.8595(c)(1-4)

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1596.8595 (c) A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in.....

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Licensee agrees to provide the Type A deficiency along with LIC 9224 dated 07/23/21 with correct dates to all parents currently enrolled and new enrollees until July 23, 2022
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This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 7 files reviewed during today's inspection, did not have LIC 9224 for Type A deficiency cited and dated 7/23/2021, this is a potential risk to children.
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(LIC 9224 printed with correct dates and provided to Licensee during this inspection along with TYPE A deficiency page which will be provided). Licensee will submit copies of LIC 9224 signed and dated by all the parents of currently enrolled children to the department by the POC date.
Type B
04/25/2022
Section Cited
HSC1596.8895(c)(1-4)

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(c)(1) Upon receipt of an accusation indicating the department's intent to revoke a facility's license, the licensee shall provide copies of a summary of the accusation to the parent or legal guardian of each child receiving services in the facility.This requirement is not met as evidenced by
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Licensee agrees to provide the Accusation documents along with LIC 9224 dated 01/10/22 with correct dates to all parents currently enrolled and new enrollees until January 10, 2023
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Based on observation and record review, the licensee did not comply with the section cited above in files reviewed did not have LIC 9224 for the Accusation dated 01/10/22 issued to the Licensee by the department which poses a potential health, safety or personal rights risk to children in care.
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(LIC 9224 printed with correct dates and provided to Licensee along with a copy of the Accusation during this inspection). Licensee will submit copies of LIC 9224 signed and dated by all the parents of currently enrolled children to the department by the POC 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: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2