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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007023
Report Date: 05/19/2021
Date Signed: 05/19/2021 01:51:11 PM

Document Has Been Signed on 05/19/2021 01:51 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:GALVEZ FAMILY CHILD CAREFACILITY NUMBER:
198007023
ADMINISTRATOR:GALVEZ, CAROLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 229-2355
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
05/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Carol GalvezTIME COMPLETED:
02:00 PM
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While conducting an investigation for a complaint, Licensing Program Analyst (LPA), Tiffanie Tran observed the following deficiency:

About 11:25 AM, during children's records review, licensee failed to provide children's records for C1 and C2.
Facility was cited a type B deficiency. See Facility Evaluation Report LIC 809D for deficiency cited.

A copy of this report was provided to the licensee and an exit interview was conducted.

Trevino Cochran
Tiffanie Tran
DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/19/2021 01:51 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 05/19/2021 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: GALVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198007023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2021
Section Cited

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Child's Records
This requirement is not met as evidenced by based on record review licensee failed to provide child #1 & #2 children's records which poses a potential health and safety risk to 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:Trevino Cochran
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2