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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198005675
Report Date: 05/01/2019
Date Signed: 05/07/2019 08:56:13 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:WALNUT VALLEY PRESCHOOL AND EARLY LEARNING CENTERFACILITY NUMBER:
198005675
ADMINISTRATOR:DR. JOSEPHINE KISAFACILITY TYPE:
850
ADDRESS:841 S. GLENWICK AVE.TELEPHONE:
(909) 595-3107
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:124CENSUS: DATE:
05/01/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Director Dr. Josephine Kisa TIME COMPLETED:
08:45 AM
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Due to computer issues on 5-1-19, the report was hand written.

Licensing Program Analyst (LPA) Ketki V Desai conducted an unannounced Case Management inspection, following a CBCB( California Background Check Bureau) Notice received on April 24th 2019 for confirmation of removal for Hernandez Martha P.
LPA met with the facility Director Dr. Josephine Kisa and the Human Resources Specialist Martha Caballero at the main school district office.
Per the Human Resource Specialist the above individual was never hired and required paperwork was never processed.
Hence the individual was not present on the premises.
No deficiencies cited per Title 22.

Exit interview conducted, a copy of this report and a Notice of Site visit was issued.

Notice of Site visit must remain posted for 30 days, failure to do so will result in a 100$ civil penalty.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (323) 981-3351
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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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