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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405662
Report Date: 06/04/2019
Date Signed: 06/04/2019 10:35:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:FLORES & JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
197405662
ADMINISTRATOR:FLORES & JIMENEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 997-0474
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:14CENSUS: 0DATE:
06/04/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Linda Flores,& Rick JimenezTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marina Pilossian arrived at the facility and met with both licensees, Mr. Flores and Jimenez. LPA did a walk through at the facility on 6/4/19 at 7:50am. LPA did not observe any day care children in the home.

According to the incident report, RP states on 5/16/19 around 4:25pm, Child #1 was observed to go to sibling Child # 2 and attempt to choke her. RP states licensee Rick immediately saw the child and removed him from and co-licensee called parent to pick up children. RP states parent came to the facility and police were called at that time by the parent. RP states the child is currently in the hospital due to the incident, does not have any further details at this time as to what else happened about why he is in the hospital. RP states other children did hear and observe Child #1 states he hated everybody and everyone is stupid and that he hated his mom and his family. RP states Child #1 never acted out before and learned yesterday that the child takes medication (does not know what kind and what for). RP states will submit additional details in written report. RP states the parent has 3 children enrolled in the facility and they returned back to care, for the exception of Child #1 whom is in the hospital at this time.

LPA interviewed both licensees, and the mother of child in question. LPA cited for missing child #!, #2, and #3 required licensing forms and immunization. Children were missing files.

Type B deficiency was cited during today's visit..

Exit interview conducted with both licensees and a copy of this report was provided.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: FLORES & JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 197405662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2019
Section Cited
CCR
102421(b)
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CHILD'S RECORDS - The LPA saw documents and other liccensing required forms missing from some of the children's files. Per Title 22 Regulation - The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7). This is a potential risk to children in the event of a medical or other emergency.
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The licensee shall submit a statement that she understands Title 22 regulations to obtain children's record and mail it to he office. Licensee provided a written statement of her understanding of children's record.
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Type B
06/11/2019
Section Cited
CCR
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPA reviewed children's files and observed missing Immunization record. Records for child #1. #2, and #3
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Licensee shall obtain copies of immunization for children and maintian them in the files. Licensee will request the parent to submit immunization records for the child.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
LIC809 (FAS) - (06/04)
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