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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191570991
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:52:22 PM


Document Has Been Signed on 08/04/2023 12:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:MAOF CHILD CARE CENTER/PICO RIVERAFACILITY NUMBER:
191570991
ADMINISTRATOR:ELIZABETH RAMIREZFACILITY TYPE:
850
ADDRESS:9125 BURKE ST.TELEPHONE:
(562) 949-3189
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:101CENSUS: 58DATE:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Teacher Samantha Jimenez TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Roxana Lopez conducted a case management inspection on this date. LPA met with Teacher Samantha Jimenez who guided analyst on a tour of the facility. Census was taken. Esther Quintero Blake, Educational Area Supervisor arrived at 10:30am.

LPA conducted today's inspection for the purpose of following up on two incidents that were reported to the Department on 6/7/2023 and 6/22/2023. The incidents were reported to the Department within the 24-hour period. Staff and children were interviewed no disclosures were made on this date.

LPA inquired about waiver request for associations on this date and obtained a copy. LPA will submit this request for department approval.

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when the incident occurred. Therefore, there are no deficiencies being cited.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Esther Quintero Blake, Educational Area Supervisor

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana LopezTELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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