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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007825
Report Date: 09/12/2019
Date Signed: 09/12/2019 03:34:57 PM

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:ESPINOZA FAMILY CHILD CAREFACILITY NUMBER:
198007825
ADMINISTRATOR:ESPINOZA, LAMBERTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 267-8331
CITY:LOS ANGELESSTATE: CAZIP CODE:
90023
CAPACITY:14CENSUS: 1DATE:
09/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:LicenseeTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffanie Tran arrived at the above facility to conduct a Case Management Incident inspection on a self-reported incident that occurred at Espinoza Family Child Care on 07/12/19. The facility made the 24 hours self-report on 07/18/19. The Monterey Park South West Office received the writing report on 07/18/19. Upon arrival, LPA met with licensee, licensee's adult daughter, licensee's mother and 2 children in care one child belongs to licensee's daughter.

LPA obtained facility roster and interviews were conducted.

Due to insufficient evidence, further investigation is required before concluding the above incident inspection. LPA advised, licensee shall report any unusual incident that occurred at the day care to the department or fax fax within the Department's next business day and during normal working hours (8am to 5pm).

Deficiency is cited during today’s inspection. Type B was cited and appeal rights was provided.

An exit interview conducted. Licensee had a copy of this report
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ESPINOZA FAMILY CHILD CARE
FACILITY NUMBER: 198007825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2019
Section Cited

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Reporting Requirements

This requirement is not met as evidenced by
based on record review facility failed to report the incident that occurred on 07/12/19 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 CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2019
LIC809 (FAS) - (06/04)
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