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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009841
Report Date: 06/26/2019
Date Signed: 06/26/2019 04:34:00 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:ALSOUROUGI FAMILY CHILD CAREFACILITY NUMBER:
198009841
ADMINISTRATOR:ALSOUROUGI, JOSEFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 413-2209
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:14CENSUS: 13DATE:
06/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Josefina AlsourougiTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Lissete Gonzalez conducted an unannounced Plan of Correction inspection to determine if if the deficiencies cited on 5/24/2019 have been corrected. Upon arrival, LPA met with Licensee Josefina Alsourougi, who provided LPA a tour of the facility inside and outside. Present during today's visit was the Licensee, 13 children (3 infants, 9 preschool age, and 1 school age) along with one assistant. LPA reviewed the children’s roster, children’s records, staff records, and a copy of the Licensee’s mandated reporter certificate.

Based on LPA’s observations and records review, the following deficiencies cited on 5/24/2019 have been corrected:
(1) 1597.465(a) - Large family day care homes; number of children
(2) 102417(g)(8) - Operation of a Family Child Care Home
(3) 102421 - Child's Records
(4) 1597.622 - Employee and Volunteer Immunization
(5) 1596.8662(c) - Mandated Reporter Training

Per California Code of Regulations Title 22, Division 12, no deficiency was cited during today's visit. Exit interview conducted with Licensee, Josefina Alsourougi.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
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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