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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493032
Report Date: 04/29/2019
Date Signed: 04/29/2019 10:47:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:FLORES FAMILY CHILD CAREFACILITY NUMBER:
197493032
ADMINISTRATOR:FLORES, PAULYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 391-9276
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:14CENSUS: 5DATE:
04/29/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Pauly FloresTIME COMPLETED:
11:00 AM
NARRATIVE
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On 4/29/19 at 8:35 AM Licensing Program Analyst (LPA) Angelica Ramirez arrived at the licensed facility to conduct a health and welfare check of children in care. LPA met with licensee Pauly Flores who guided the LPA on a tour of the facility. Also present during the inspection is the licensee's assistant, individual 1 (licensee's guest visitor) and five day care children.

An inspection of the facility was conducted, copies of facility documents and children's records were obtained and interviews were conducted with children in care.

During the inspection no immediate danger was observed to children in care.

A Type B deficiency was cited during today's inspection, see LIC809-D for details.

A copy of this report was read and provided to the licensee and a notice of site visit was provided to be posted for 30 days.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Angelica RamirezTELEPHONE: (661) 369-2168
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 197493032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2019
Section Cited
HSC
1597.622(a)(1)
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Commencing September 1, 2016, a person shall not... volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles... This requirement was not met as evidenced by: based on observation
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Licensee agrees to ensure that Individual 1 has no contact with day care children until her departure date 5/14/19. Licensee will provide a signed declaration stating how she intends to keep Individual 1 away from day care children by 5/3/19.
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This requirement was not met as evidenced by: based on observation, individual 1 was providing care to day care children and was not immunized against pertussis, measles, influenza. This poses a potential danger 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: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Angelica RamirezTELEPHONE: (661) 369-2168
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019
LIC809 (FAS) - (06/04)
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