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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010360
Report Date: 04/05/2021
Date Signed: 04/05/2021 03:48:22 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:VELASCO & CASILLAS FAMILY CHILD CAREFACILITY NUMBER:
198010360
ADMINISTRATOR:VELASCO, A. & CASILLAS A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 480-8156
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:14CENSUS: 8DATE:
04/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Deserie VelascoTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Vasquez contacted the facility via telephone by Facetime due to COVID-19 and precautionary measures. LPA Vasquez conducted an unannounced Case Management Incident inspection as a continuation of an investigation initiated on 03/19/21. LPA spoke with co-licensee Deserie Velasco, who guided LPA on a visual tour of the facility.

Census: There were 8 children and 2 staff present. Staff-child ratio was met.

During this investigation, LPA conducted interviews with two staff, one parent and two children. LPA obtained Children’s roster, a medical information printout and pictures taken during the virtual tour of the slide and swing set bar.

The incident that occurred on 3/17/21 was reported to the Department on 03/18/21 via telephone and fax. Information reported to the Department indicated that (C1) sustained a dislocated elbow.

(C1) was playing outdoors with (C2, C3, C4, C5), (C1) jumped off the last step of a portable mini slide to reach for a bar that is attached to a swing set, missed the bar and landed on arm statements were made that (C2 and C3) took (C1) to the licensee in the garage after the fall. The two children interviewed stated there were no adults outside with them. When licensee was asked if she saw (C1) fall, she replied I didn't see her hit the floor, Per licensee she was asking the other children where did she hit, show me.

Based on the evidence as presented above, it has been determined that there was a lack of supervision, as there were no adults supervising when the children were playing outside, the lack of supervision/this posed an immediate risk to the health and safety of the children in care, as it resulted in (C1) sustaining a dislocated elbow.
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
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 3
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: VELASCO & CASILLAS FAMILY CHILD CARE
FACILITY NUMBER: 198010360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/05/2021
Section Cited

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Operation of a Family Child Care Home: The licensee shall be present in the home and shall ensure that children in care are supervised at all times.

This requirement was not met as evidenced by: (C1) falling outdoors sustaining a dislocated elbow.
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 Per licensee she did not see her hit the floor,licensee asked the chidlern where did she hit, can you show me. This poses an immediate risk to the health and safety of children in care.
A civil penalty in the amount of $500 has been assessed, as this is a Zero Tolerance citation
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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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: VELASCO & CASILLAS FAMILY CHILD CARE
FACILITY NUMBER: 198010360
VISIT DATE: 04/05/2021
NARRATIVE
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The following deficiencies listed on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22. and an immediate Zero Tolerance civil penalty in the amount of $500 is being assessed.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent.

Exit interview was conducted with Deserie Velasco, co-Licensee, including, but not limited to Provider Rights, Appeal Procedures. A Notice of Site Visit was not provided to co-licensee since a physical inspection was not conducted.

A copy of form LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided during this visit.



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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3