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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011174
Report Date: 10/01/2019
Date Signed: 10/01/2019 09:09:37 AM

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:FIALLOS FAMILY CHILD CAREFACILITY NUMBER:
198011174
ADMINISTRATOR:FIALLOS, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 232-3292
CITY:LOS ANGELESSTATE: CAZIP CODE:
90037
CAPACITY:14CENSUS: 6DATE:
10/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rosa Fiallos, LicenseeTIME COMPLETED:
09:25 AM
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VISIT CONDUCTED IN SPANISH
Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection on this date. Upon arrival, LPA met with Licensee Rosa Fiallos. Also present were assistant's Magaly Montenegro and Aura Godoy. There were 6 children present during inspection.

On 9/26/19, Licensee submitted an unusual incident/injury report to the Department. LPA interviewed licensee. LPA reviewed child's record and reviewed pertinent documentation. Per report Child #1 had an issue with diapering at the facility. LPA reviewed documents and medical information. Child was taken to obtain medical care. Licensee received medical documentation and submitted to Department on 9/27/19. Child #1 was cleared by doctor's note to return to school 9/27/19.

LPA observed Child #1 at the facility during visit engaging in activities. No signs of discomfort.

Based on information obtained, LPA determined there were no violations that resulted from the incident. No deficiencies were cited on this date. Licensee met reporting requirements for this incident.


Exit interview conducted with Licensee Rosa Fiallos. A copy of this report was provided. Notice of Site Visit was issued and must remain posted in the facility for 30 days. Failure to do so will result in a civil penalty.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2019
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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