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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415142
Report Date: 10/28/2020
Date Signed: 11/18/2020 09:00:53 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:KSIESKI FAMILY CHILD CAREFACILITY NUMBER:
197415142
ADMINISTRATOR:KSIESKI, CAROLINE A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 227-9146
CITY:WESTCHESTERSTATE: CAZIP CODE:
90045
CAPACITY:12CENSUS: 10DATE:
10/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:InterviewTIME COMPLETED:
12:45 PM
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On October 28th, 2020 Licensing Program Analyst Lisa Rios conducted a case management incident inspection via phone (due to Covid-19) to discuss the incident that took place during non-operational hours of the Family Child Care on 5/13/2020. Please see LIC812 dated 10/29/2020 for details.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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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