Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016602
Report Date: 10/20/2015
Date Signed 10/20/2015 04:19:15 PM

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:GUERRERO FAMILY CHILD CAREFACILITY NUMBER:
198016602
ADMINISTRATOR:GUERRERO, ESTELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 966-4760
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:14CENSUS: 4DATE:
10/20/2015
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Estela GuerreroTIME COMPLETED:
04:30 PM
NARRATIVE
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During the course of a case management visit conducted this date by Complaint Specialist-LPA, Karen Chambers, the following was observed and is being cited in accordance with Title 22, California Code of Regulations, Division 12, Chapter 3:

1. The roster that the Licensee provided was in complete. There were 8 names missing from the roster.

The notice of site visit was posted where the parent/guardian of children in care enter and exit the facility. This notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview was conducted this date with the Licensee, during which the appeal rights were explained and provided.
SUPERVISOR'S NAME: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)854-7636
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2015
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


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: GUERRERO FAMILY CHILD CARE
FACILITY NUMBER: 198016602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2015
Section Cited
102417(g)8
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Operation of a Family Child Care Home. All homes shall have a current roster of the children. The roster that the Licensee provided was incomplete, there were 8 names observed to be missing. This is a potential risk to the health and safety of children in care if not corrected.
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Per the Licensee: I gonna put in on the roster and fax.


323.981.3355
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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: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)854-7636
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2