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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492911
Report Date: 05/10/2019
Date Signed: 05/10/2019 08:34:04 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:NEVAREZ FAMILY CHILD CAREFACILITY NUMBER:
197492911
ADMINISTRATOR:NEVAREZ, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 892-1486
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:14CENSUS: 4DATE:
05/10/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:20 AM
MET WITH:Elizabeth NavarezTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA), Marina Pilossian conducted a Case Management visit. LPA Pilossian met with licensee Elizabeth Nevarez on 05/10/19 at 7:20 am. LPA observed licensee, her spouse and four children including licensee's minor son (2 infants, 2 pre school age). LPA explained licensee that the Department has received a Conditional Exemption Approval letter CBCB 4.01 letter for Jose Gonzalez.

LPA Pilossian explained to the licensee, and spouse the conditional Exemption approval for Jose Gonzalez:
1. Does not transport clients.
2. The individual does not violate any licensing laws or regulations.
3. The individual does not engage in conduct that indicates that he/she may pose a risk to the health and safety of any individual who is or may be a client.
4. The individual does not fail to disclose a conviction even if it occurred before the exemption was granted.
5. The individual is not convicted of a subsequent crime.

The conditions of the of exemption were read to licensee and licensee's spouse Jose Gonzalez. Licensee was in agreement with conditions that was read from 1 to 5 and does not wish to appeal. LPA explained to licensee this conditional exemption applies only to the facility number identified above. LPA reviewed the facility profile and personnel record. LPA Pilossian provided one copy of the conditional Exemption Approval letter CBCB-4.10 to the licensee during the visit.

Exit Interview was conducted and a copy of this report was submitted to licensee during the visit.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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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