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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004449
Report Date: 09/18/2019
Date Signed: 09/18/2019 10:38:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SALAZAR FAMILY CHILD CAREFACILITY NUMBER:
198004449
ADMINISTRATOR:SALAZAR, ALEXANDRIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 948-1569
CITY:SANTA FE SPRINGSSTATE: CAZIP CODE:
90670
CAPACITY:14CENSUS: 4DATE:
09/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:LicenseeTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tiffanie Tran and Attorney Jonathan Gibson arrived at the above facility to conduct a Case Management Incident inspection on a self-reported incident that occurred at Salazar Family Child Care on 05/21/19. The facility made the 24 hours self-report on 05/22/19. The Monterey Park South West Office received the writing report on 05/30/19. During the inspection, LPA observed proper care and supervision.

LPA completed child file review. LPA obtained child's document, and children's roster.
LPA conducted interviews and it revealed that on the day of the incident, licensee provided care for 5 child care children. During afternoon indoor play in the play room area, C1 was stepping backward, tripped on the hard plastic block and fell hit the back of his head on the floor. C1 had blood around his nostrils and sustained a small bump on the back of his head. Ice pack was applied. Mother was contacted. Per mother, C1 was taking to family doctor for check up the same day. C1 observed to be fine and able to return to daycare the next day. No changes in behavior. At this time based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision. No deficiency was found during today's inspection.

The content of this report was read and discussed in detail at the time of with the noted contact person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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