<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191606870
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:28:37 PM


Document Has Been Signed on 10/08/2024 12:28 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:CITY OF CARSON COMMUNITY SERVICE CENTERFACILITY NUMBER:
191606870
ADMINISTRATOR:RAQUEL RIVERAFACILITY TYPE:
850
ADDRESS:801 E. CARSON ST.TELEPHONE:
(310) 835-0212
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:70CENSUS: 51DATE:
10/08/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:RAQUEL RIVERA / DIRECTORTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPA) LPA Ashley Calderon arrived to the facility. The purpose of the inspection was to conduct a complaint inspection. Due to LPA observations, interview, and record review LPA conducted a Case Management inspection.

Incident was reported by the facility on 10/2/24 via telephonically to caseload LPA Susan Sanchez, failed to report to the Department within the next working day. Per Facility Director notified LPA Calderon Child #1 parents spoke to her on 9/26/24 regarding incident that took place on 09/24/24.

As of 10/8/24 at 11:33am, written incident report was not submitted to Licensing within the 7 day time frame.

The following deficiencies listed on the attached LIC 809-D (deficiency page) are being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 1 and Section CCR.

An exit interview was conducted with Staff/ Director Raquel Riviera, Appeal Rights and Notice of Site visit was given.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
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 2


Document Has Been Signed on 10/08/2024 12:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: CITY OF CARSON COMMUNITY SERVICE CENTER
FACILITY NUMBER: 191606870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
Section Cited
CCR
101212

1
2
3
4
5
6
7
(d) Upon...occurrence, during the operation of...center of any of the events specified...below, a report shall be made to the Depart. by telephone or fax within... next working day...during its normal business hours. In addition, a written report containing the information specified in (d)(2)...
1
2
3
4
5
6
7
Director provided LPA with City of Carson In House Incident Report and Staff Statements. In addition, Director will submit to Licensing Via email on 10/8/24, LPA provideded the LIC624 Unusal Incident Report and Regulation on reporting requirement.
8
9
10
11
12
13
14
below shall be submitted to the Department within seven days following the occurrence of such event. The requirement was not met as evidanced by: Director Raquel during itnerviewed confirmed was unaware of Reporting Requirments and stated no written UIR sent to Licesning. Called Licensing caseload LPA on 10/2/24 and incident was reported on Thur. 9/26/24.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2