Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300439
Report Date: 05/18/2015 12:00:00 AM
Date Signed 05/18/2015 01:51:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ORTIZ, GLORIAFACILITY NUMBER:
304300439
ADMINISTRATOR:ORTIZ, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 534-0361
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 5DATE:
05/18/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gloria Ortiz and assitant Alicia VillalbaTIME COMPLETED:
02:15 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
Lpa Nevarez-Martinez met with licensee and her assistant in order to conduct an annual/random visit to the home. Lpa with Licensee Gloria Ortiz and her niece/assistant Alicia Villalva, census was taken of 5 day care children who were napping at time of visit. Lpa toured back yard noticed that all in the home is clean and orderly no hazards accessible at time of visit. Age group in the home is one infant and 4 toddlers. Sign in/out sheet by the entry door. Licensee was home cooking and cleaning while the children napped. Licensee provided children's files and CPR and First Aid 07/19/2016. The purpose of this visit was to conduct an Annual visit. Lpa reviewed files and toured the facility. She stated that she has after school children coming at 3:00 PM.
Lpa tested Fire Alarms which are working and Fire extinguisher was visible. A review of staff records on 05/11/2015 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. Web site addresses http://www.ccld.ca.gov and http://www.dss.cahwnet.gov were given to down load forms and Title 22 regulations.
LPA informed licensee of current regulations and current forms. AB 633 fact sheet had been given to the facility representative at a prior visit. http://www.dss.ca.gov/
The home is clean and clear, no defects, back yard has play equipment.

An exit Interview was conducted, Appeal rights were explained and a copy given. All appeals must be in writing and received by the licensing office within 10 days.
THE NOTICE OF SITE VISIT WAS POSTED AND DISCUSSED AS REQUIRED BY H&S CODE SEC. 1596.817. This report must be filed in your facility file for public review for 3 years after being posted for 30 days. Failure to post will result in civil penalties of $100.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2015
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 1