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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191570967
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:23:27 PM


Document Has Been Signed on 09/21/2023 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:TRACY INFANT CENTERFACILITY NUMBER:
191570967
ADMINISTRATOR:TOM WOODWARDFACILITY TYPE:
830
ADDRESS:12222 CUESTA DRIVE, BLDG FTELEPHONE:
(562) 229-7762
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:62CENSUS: 9DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dr. Rebecca LynchTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. Tran conducted an unannounced Case Management Incident visit at Tracy Infant Center to follow up self reported incident occurred on 08/31/2023 regarding care and supervision. The Monterey Park South West Office received the writing report on 08/31/2023. LPA met with Dr. Rebecca Lynch, Supervisor Child Development and Special Program. LPA observed proper care and supervision.

LPA completed child review. LPA obtained child's document, children's and personnel report.
Interviews were conducted with staff and other. On the day of the incident, there were 9 children with three teachers. Parent was notified of the incident. Based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.

No deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Dr. Rebecca Lynch.

SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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