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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415142
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:25:09 PM


Document Has Been Signed on 03/24/2022 02:25 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
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: 13DATE:
03/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Caroline KsieskiTIME COMPLETED:
02:35 PM
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On 3/24/2022 at 1:58 pm, Licensing Program Manager (LPM) Lisa Rios and Licensing Program Analyst (LPA) Deborah Lowe arrived at facility to discuss an amended LIC 809 Facility Evaluation Report for a visit that was conducted on 2/03/2022. LPM Rios and LPA Lowe met with Licensee, Caroline Ksieski.

LPM Rios and LPA Lowe toured facility and observed 13 children under supervision of licensee and 2 staff. LPM and LPA verified staff present have a criminal background clearance.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

An exit interview was conducted and a copy of this report (LIC 809) and Notice of Site Visit were provided to Caroline Ksieski.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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