Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018196
Report Date: 03/29/2016
Date Signed 03/29/2016 11:32:51 AM

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:CHILDREN'S COLLECTIVE INC - MAPLE STREET, THEFACILITY NUMBER:
198018196
ADMINISTRATOR:CHENIEKA MORGAN-MILLSFACILITY TYPE:
850
ADDRESS:255 EAST 28TH STREETTELEPHONE:
(310) 733-4388
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:36CENSUS: 28DATE:
03/29/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Loretta IberosiTIME COMPLETED:
11:45 AM
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This visit was conducted by Complaint Specialist -LPA, Karen Chambers and LPA Ariel Cazares. The purpose

of this visit was to obtain a copy of the facility roster as it relates to the incident that was report on 3/23/16 where a
child's personal rights may have been violated.

At this time additional information is needed to conclude the investigation into the above incident.

During this visit a copy of the roster was made available.

The notice of site visit was posted where the parent/guardian of children 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 with Loretta Iberosi
SUPERVISOR'S NAME: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)854-7636
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2016
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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