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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412222
Report Date: 11/24/2020
Date Signed: 11/24/2020 05:31:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:CABRERA FAMILY CHILD CAREFACILITY NUMBER:
197412222
ADMINISTRATOR:CABRERA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 965-1080
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:14CENSUS: 12DATE:
11/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:GUADALUPE CABRERATIME COMPLETED:
04:30 PM
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On November 24, 2020 at 2:30 PM Licensing Program Analyst, Loyce Phillips contacted Licensee, Guadalupe Cabrera for a Case Management Tele-Visit inspection involving an Unusual Incident Report (UIR) received by email on 11/22/2020.

Description of the incident: The incident occurred on 11/18/2020 child 1 was playing outside when he urinated on himself in a box. Child 1 went to staff 3 and stated "look I pee'd." Staff 3 asked why did you do that and child responded "I don't know" and started smiling and laughing. Later that evening, parent 1 question her child "why did you urinate on yourself?" Child 1 responded "because child 2 touched my private area."

During the Tele-Visit inspection, LPA received a census of the children present, interview staff, toured the backyard area and requested pertinent documentation related to the incident.

Based on the information provided and interviews conducted the incident will require further investigation.

An exit interview was conducted, the report was read and has been emailed for a read receipt to Licensee, Guadalupe Cabrera.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (661) 305-5243
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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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