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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192010484
Report Date: 06/26/2023
Date Signed: 06/26/2023 02:52:08 PM


Document Has Been Signed on 06/26/2023 02:52 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:AYALA FAMILY CHILD CAREFACILITY NUMBER:
192010484
ADMINISTRATOR:AYALA, DONIELLE FELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 999-2508
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:14CENSUS: 5DATE:
06/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Donielle AyalaTIME COMPLETED:
03:17 PM
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An unannounced Case Management Inspection was conducted on 06/26/23 by Licensing Program Analyst (LPA) Raul Navarro to address an Unusual Incident Report that was received in the licensing office on 05/19/23. LPA arrived at the facility at 02:10pm and met with Licensee Donielle Ayala who guided LPA on a tour of facility. There were five children present during today's inspection.

On 05/19/23 at about 12pm, Child #1 was eating a hot dog. Child stuffed their mouth and began to choke. Licensee administered first aid and called 911.

LPA interviewed the Licensee. Per Licensee Donielle Ayala, they observed the incident as it happened. Per Licensee, the children were eating at the table in the dining room near the kitchen. Licensee was in the kitchen adjacent to the dining room and heard the child choking. Licensee went to child and immediately administered first aid. Licensee also called 911 and the child's parent. Ambulance and parent arrived and checked on the child. Child was okay and parent kept child in the facility for the remainder of the day of the incident. Child is still enrolled at the facility.

Based on all information obtained on this date, and interview conducted with Licensee, no follow-up is necessary regarding the incident. There were no deficiencies observed in regards to today's visit.

Exit interview was conducted with Licensee Donielle Ayala . A notice of sit visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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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