Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312394
Report Date: 11/10/2016
Date Signed 11/10/2016 05:07:01 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:HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTOFACILITY NUMBER:
304312394
ADMINISTRATOR:AREVALO ESPERANZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 415-9125
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:14CENSUS: 3DATE:
11/10/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mr. ArevaloTIME COMPLETED:
05:15 PM
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The purpose of this visit was to conduct a case management visit of the facility due to an incident that the facility reported to our office on 11/09/16. According to the self-reported incident, a child sustained an injury while at the facility. Complaint Specialist Hundley met with Ms. Green who was caring for 3 children. Ms. Green informed CS that licensee was not present and she was transporting a child to the facility. Mr. Arevalo was present but in another room. CS spoke with Mr. Arevalo and Ms. Hernandez-Arevalo about the incident. There is no deficiencies during today's date for this incident. The facility was in compliance at the time of visit.

Exit interview conducted.

THE NOTICE OF SITE VISIT WAS POSTED AND DISCUSSED AS REQUIRED BY H&S CODE SEC. 1596.817. The Notice of Site Visit form (LIC 9213) must be posted for 30 days. Failure to post will result in civil penalties of $100.”
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Minerva HundleyTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2016
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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