Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018224
Report Date: 11/07/2017
Date Signed 11/08/2017 10:10:04 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:SMITH FAMILY CHILD CAREFACILITY NUMBER:
198018224
ADMINISTRATOR:SMITH, HARRIETFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 756-3332
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:14CENSUS: 7DATE:
11/07/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Harriet Smith TIME COMPLETED:
03:45 PM
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Cynthia Reyes, Licensing Program Analyst, (LPA) conducted an unannounced Case Management-Incident report visit. There was one (1) Incident report that came into the office on 07/10/17.

LPA Met with Licensee Harriet Smith, who guided the analyst on a tour of the facility. LPA interviewed, reviewed and received records during an Inspection visit on 07/26/2017. LPA went over Incident report with Ms. Smith. Report was documented by the department the same day the LPA made a inspection on 07/26/17, however was received by mail on 07/10/17.

Based on information obtained on this date, no follow up is necessary regarding the incident report listed above. The incident dated 07/10/17 is Unsubstantiated .

Exit interview conducted and a copy of this report was left with Licensee Harriet Smith
No Citation given.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323)981-3380
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2017
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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