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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402255
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:04:43 PM


Document Has Been Signed on 02/28/2024 04:04 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:CHANG FAMILY DAY CAREFACILITY NUMBER:
197402255
ADMINISTRATOR:MARIA DE JESUS CHANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 253-7308
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:14CENSUS: 1DATE:
02/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Maria De Jesus Chang, LicenseeTIME COMPLETED:
04:25 PM
NARRATIVE
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On Wednesday, February 28, 2024, Licensing Program Analyst (LPA) Mayra Rivera conducted a Case Management inspection to amend the civil penalty that was issued to licensee on August 11, 2023 for having one adult present without a criminal record clearance and licensee failed to obtain a California clearance and/or a criminal record exemption as required by the Department for adult #1 (licensee’s daughter's partner).

The facility was issued a Type A citation on August 11, 2023, for (d). All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility. Licensee did not sign LIC 421BG CIVIL PENALTY ASSESSMENT – CAREGIVER BACKGROUND CHECK form that was issued on August 11, 2023 by LPA Ortega. LPA Rivera amended the Type A and civil penalty. LPA Rivera issued the civil penalty for $100.00.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Maria De Jesus Chang.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 04:04 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: CHANG FAMILY DAY CARE
FACILITY NUMBER: 197402255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2023
Section Cited
CCR
102370(d)(1)

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102370 Criminal Record Clearance (d)(1) All individuals...shall prior to working, residing, or volunteering in a licensed facility...Obtain a California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
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LIcensee will ensure uncleared Adult #1 is off of the homes property and ensure that uncleared Adult #1 does not come on the homes property until fingerprinted, cleared and associated to the facility.
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Based on observation uncleared Adult #1 accesses the homes back door when children are present during the hours of operation, which poses an immediate Health, Safety or Personal Rights risk to children in care.
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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: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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