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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414463
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:41:31 PM


Document Has Been Signed on 05/22/2023 04:41 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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:ROA FAMILY CHILD CAREFACILITY NUMBER:
197414463
ADMINISTRATOR:ROA, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 219-1677
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 5DATE:
05/22/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:CARMEN ROA, LICENSEETIME COMPLETED:
05:00 PM
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On 05/22/2023, Licensing Program Analysts (LPA) Loyce Phillips and Judy Laureano made an unannounced case management legal/non-compliance visit to Roa Family Child Care Home (FCCH) for the purpose of delivering an Immediate Exclusion Order for Jose Roa, licensee’s son. LPA observed 5 children in care with Licensee, assistant and 2 other adults in the home.

The order to Immediately Exclude Jose Roa was discussed in detail with licensee. Licensee is aware that Jose Roa must not be physically present in the Family Child Care Home, nor can he have contact with children in care. Licensee acknowledges the receipt of the Immediate Exclusion Order dated May 22, 2023. LPA advised licensee that parents in care must be provided a copy of LIC 995B, and a copy of this form must be maintained in each child’s file.

An exit interview was conducted, and a copy of this report, notice of site visit and appeals rights was provided to Licensee Carmen Roa.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (310) 740-3038
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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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