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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010360
Report Date: 04/25/2022
Date Signed: 04/25/2022 01:40:35 PM


Document Has Been Signed on 04/25/2022 01:40 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 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: 2DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Deserie Velasco, LicenseeTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Fabiola Vasquez and Lilli Babcock conducted a case management inspection due to an incident that occurred on 04/01/22. LPA met Licensee, Deserie Velasco who guided LPAs on a tour of the facility. During this inspection LPAs observed 2 children 1 being an infant with Licensees and Co- licensee.
The incident that occurred on 04/01/22 was reported to the Department on 04/01/22 . The facility reported the incident in a timely manner.
LPA conducted an interview with S1 and S2, LPAs also observed a picture of the high chair that the child was utilizing when the incident occurred on Licensee cell phone. LPAs observed the new purchased high chair.

On 04/01/22 S1 was finishing feeding C1, as she was getting C1 out of the highchair she bend forward to pick up the lid. C1 slid forward and hit his head on the kitchen ceramic tile floor leaving him a bump on his forehead. Due to child's age Licensee advised the mother to take him to the emergency room. The injury required medical attention. Based on doctors X-rays report there was no evidence of acute fracture,

LPAs observed a picture of the highchair and verified with the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ that the chair was not a recall item. LPAs observed that licensee purchased a new high chair one that is intact and does not require the feeding tray to be taken off when child is removed. Statements made by S1 and S2 that child had finished eating and licensee was holding him and C1 was wiggling and slid out the arms. LPAs determined there was adequate supervision provided the day of the incident, no follow-up is necessary regarding the incident.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Exit interview conducted with the Deserie Velasco, Licensee
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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