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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492759
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:17:12 PM


Document Has Been Signed on 09/06/2022 03:17 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:ESCOBAR FAMILY CHILD CAREFACILITY NUMBER:
197492759
ADMINISTRATOR:ESCOBAR, HEIDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 216-7137
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:14CENSUS: 11DATE:
09/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Heidy Escobar, Licensee and two Licensee's assistant TIME COMPLETED:
03:20 PM
NARRATIVE
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On 09/6/2022, 2:50pm, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management - Deficiencies for the purpose of the health and safety of the family child care.
LPA Miranda observed 11 children (who 2 were infants) in care with licensee, and two assistants. Per licensee she has 15 children enrolled on her family child care. Per Licensee the 15 children are not attending at the same time.

During this visit, Licensee was unable to produce the safe sleep log for child#1. LPA provided a copy of title 22 – Infant Safe Sleep and Brochure of SIDS.

An advisory notes was provided to Licensee, due a current Child Care Facility Roster : Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D)

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Heidy Escobar, Licensee.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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Document Has Been Signed on 09/06/2022 03:17 PM - 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: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 197492759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited

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Infant Safe Sleep - (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:a. Date, b. infant's name
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c. Time of each 15-minute check.This requirement is not met as evidence by on 9/6/2022, Licensee was unable to produce copy of safe sleep log for child#1, that was present on 8/30/22 while an incident happened involving this child.
This poses a potential H&S Children in care.
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a copy of the agenda and the topics of the training no later thant 09/09/2022.

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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: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
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