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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419985
Report Date: 05/25/2023
Date Signed: 05/26/2023 11:14:08 AM


Document Has Been Signed on 05/26/2023 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:VILLAGRANA FAMILY CHILD CAREFACILITY NUMBER:
197419985
ADMINISTRATOR:VILLAGRANA, LAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 800-2610
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:14CENSUS: 2DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:VILLAGRANA, LAURA- LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
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On 5/25/2023, Licensing Program Analyst's (LPA) Suzette Ornelas conducted an unannounced case management inspection for the purpose of deficiencies observed during a complaint investigation on 5/12/2023 for complaint control # 58-CC-20230508160820. Upon arrival LPA was greeted by Licensee, VILLAGRANA, LAURA and observed 2 children and 1 adult.

LPA Ornelas investigated complaint control # 58-CC-20230508160820. According to the complaint investigation report received on 5/8/2023, Licensee did not prevent day care child from wandering from the facility on 2/14/2023.

Based on interview conducted with license, licensee stated that due to Police Officer 1 (PO1) and Police Officer 2 (PO2) informed her that the incident was going to be reported, she did not report it herself. It was confirmed that the incident was not reported to the Department within 24 hours. No direct contact with the on duty worker or the analyst was made within 24 hours.
LPA explained to the licensee that when an incident occurs, according to Title 22 Regulations, the incident must be reported to the department within 24 hrs., and a written report using the unusual incident /injury report LIC624 form must be filled out and mailed to the department within 7 days. Licensee understands and will comply.

The following Type B deficiency is being cited on 5/25/2023 in accordance to Title 22 of the California Code of Regulations: 102416.2 Reporting Requirements. "A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home of…the…events." (Please refer to 809D for cited deficiencies.)

A copy of this report, notice of site visit, and appeal rights were provided. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with licensee.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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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Document Has Been Signed on 05/26/2023 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: VILLAGRANA FAMILY CHILD CARE
FACILITY NUMBER: 197419985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2023
Section Cited
CCR
101212(d)(1)

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 Reporting Requirements: (d) The licensee shall report to the Department as provided by Health and Safety Code Sections 1597.467(b)(1) and (2). "A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home of…the…events."
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LPA informed licensee of reporting requirements. The importance of telephoning the incident and following up with the required written report. Licensee will provide LPA with a written statement indicating she will ensure that any unusual incidents are reported as required. LPA will obtain a written UIR LIC624 from licensee.
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This requirement is not met as evidenced: On 02/14/2023 child wandered from the facility. Licensee did not report to CCLD as unusual incident.
This is a type B dificiency as poses a potential risk to the health and safety of children in care.
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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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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