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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500276
Report Date: 05/08/2019
Date Signed: 05/08/2019 11:29:43 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN WEST PRESCHOOLFACILITY NUMBER:
191500276
ADMINISTRATOR:SANDRINE BELLAIRSFACILITY TYPE:
850
ADDRESS:10248 ALONDRA BLVD.TELEPHONE:
(562) 866-5616
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:80CENSUS: 60DATE:
05/08/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:LaReina VelasquezTIME COMPLETED:
11:45 AM
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A Case Management inspection was conducted by Licensing Program Analyst, Timothy Fields. LPA met with LaReina Velasquez. The purpose of today's inspection was to interview children, and obtain April 11, 2019 time-sheets and sign-in/out sheets for staff and children. Requested documents will be received by email on 5/10/19. LPA reviewed children's records and documented parent contact information.

Exit interview conducted with office assistant LaReina Velasquez. Appeal Rights provided and explained. Notice of Site Visit must be posted for (30) days. Failure to do so may result in a $100.00 civil penalty.

Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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