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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198012910
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:49:04 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Betty Bell
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20211223112943
FACILITY NAME:JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
198012910
ADMINISTRATOR:JIMENEZ, VERONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 633-2083
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:14CENSUS: 13DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee Veronica JimenezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee does not live in the childcare home

Licensee is operating over ratio
INVESTIGATION FINDINGS:
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An unannounced, in-person, follow-up Complaint inspection was conducted on 03/21/22 by Licensing Program Analysst (LPA) Emiko Bell and Steven Tung. Upon arrival, LPAs were greeted by Licensee Veronica Jimenez, to whom the purpose of the inspection was announced. The purpose of this inspection was to provide the findings of the Complaint investigation

The COVID screening questions were posed to Licensee Veronica Jimenez. Throughout the duration of the inspection, LPA wore face coverings as a precautionary measure against COVID-19.

Upon LPA's arrival at 10:40, Licensee Veronica Jimenez and her two assistants were outdoors on the patio with 13 children, as lunch was being served. All staff are cleared and associated.

Staff-child ratio was not met; license was out of ratio.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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Throughout the course of the investigation, interviews were conducted with four staff, the Reporting Party (RP), and one Adult; and documentation in the form of the Child Care Facility Roster, photos, and documentation of property records were obtained.

-Pertaining to the allegation that “Licensee does not live in the childcare home”:

the allegation refers to RP noticing that Licensee Jimenez was not at the daycare at pick up time, between 05:00 and 05:30 pm. According to two of the four staff interviews conducted on 12/29, two persons live in the residence, Licensee Jimenez and her daughter, Kimberly. According to licensee, she has been leasing the residence from her “ex”-husband for about 8-10 years, but could not provide a lease agreement. When asked to provide verification that she leases/pays the rent of the residence, licensee provided a property tax statement which has the names of her and her “ex” husband on there. When asked why her name is on there, if she simply leases the property, licensee stated, “that is the way Los Angeles County does it.” When LPA Bell toured the residence on 12/29/21, the residence was in disarray and several baby items were observed. After LPA inquired as to why there were baby items in the living room, Licensee stated that her sister, her cousin and two sons will occasionally live in the residence (only two of these persons named have Criminal Background Clearance). Upon LPAs’ arrival at the residence on 12/29/21, packages were observed on the front porch with the name of a male (identified as the previous owner, who, the licensee states, still receives mail at the residence, though he has not lived there for 16 years) and of a female, whom licensee identified as her “homeless cousin.”

Two of the staff interviewed had varying responses as to whom lives in the residence when interviewed on 12/29/21 and on 03/14/22: one staff named four persons who live in the residence (only two of whom have Criminal Background Clearance) then changed their response to six

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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people (only three of whom have Criminal Background Clearance); while another staff stated that there were two persons who lived in the residence, but the persons named changed between the 12/29 and the 03/14 interviews (but at least one of whom does not have Criminal Background Clearance). It must be noted that there are only two usable bedrooms in the residence. Documentation obtained by LPA verifies that licensee and her “ex” spouse live in and own a residence in La Verne.

Based upon LPAs’ observations, as well as the disclosures made by the two adults and the Reporting Party, and the documentation of property records obtained, the allegation that “Licensee does not live in the childcare home” has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 01, Section 102352 Definitions is being cited on the attached LIC 9099D.

-Pertaining to the allegation that “Licensee is operating over ratio”:

The allegation pertains to RP’s knowledge that licensee cares for between 14-20 children and used to have five staff, but now only has three staff.

During the 03/14/22 inspection, when LPAs’ arrived at 10:20 am, there were three staff and 12 children ages 5, 4, 4, 3, 3, 3, 3, 2, 2, 2, 2, and an infant. At 10:30 am, the 13th child, age 4, arrived. Regulation 102416.5 states that, “A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met…At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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At 11:20, one of the 4-year-old children was picked up. As there was not a child at least six years of age present from 10:30-11:20 am, as required, licensee was out of ratio for 50 minutes.

Based upon LPAs’ observations, and the documentation from the Child Care Facility Roster, the allegation that “Licensee is operating over ratio” has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section 102416.5 Staffing Ratio and Capacity is being cited on the attached LIC 9099D.

A Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Bell informed Licensee Veronica Jimenez that this report dated 03/16/22 documents one Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Bell informed Licensee Veronica Jimenez to provide a copy of this licensing report dated 03/16/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly-enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Licensee Veronica Jimenez.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
102352(f)(1)
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DEFINITIONS
"Family Day Care" or "Family Child Care" means regularly provided care, protection and supervision of children, in the care giver's own home, for periods of less than 24 hours per day, while the parents or authorized representatives are away. The term "Family Child Care" supersedes the term "Family Day Care" as used in previous regulations
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Licensee will provide bills, etc., as well as write a Declaration stating that she understands the regulation and writing out in which of her four residences she actually resides.
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-This requirement is not met as evidenced by: interviews conducted and documentation obtained show that though licensee may own the residence, she lives in a residence in La Verne. *This poses an immediate risk to the health and safety of the children in care.*
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Type A
03/22/2022
Section Cited
CCR
102416.5d)(2)(a)
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Staffing Ratio and Capacity
A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met…At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.
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Licensee will provide LPAs with the children's schedules and inform LPAs who she may disenroll or put on a scheudle.
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-This requirement is not met as evidenced by: on 03/14/22, at 10:20 am, there were 12 children present. At 10:30, the 13th child, a 4-year-old, arrived. Licensee was out of ratio from 10:30-11:20, when one of the 4-year-old children was picked up. *This poses an immediate risk to the health and safety of the 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 11 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Betty Bell
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20211223112943

FACILITY NAME:JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
198012910
ADMINISTRATOR:JIMENEZ, VERONICAFACILITY TYPE:
810
ADDRESS:1302 POPS ROADTELEPHONE:
(626) 633-2083
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:14CENSUS: 13DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee Veronica JimenezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee is operating over capacity

Licensee does not spend a sufficient amount of time in the childcare home

Child sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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An unannounced, in-person, follow-up Complaint inspection was conducted on 03/21/22 by Licensing Program Analysst (LPA) Emiko Bell and Steven Tung. Upon arrival, LPAs were greeted by Licensee Veronica Jimenez, to whom the purpose of the inspection was announced. The purpose of this inspection was to provide the findings of the Complaint investigation

The COVID screening questions were posed to Licensee Veronica Jimenez. Throughout the duration of the inspection, LPA wore face coverings as a precautionary measure against COVID-19.

Upon LPA's arrival at 10:40, Licensee Veronica Jimenez and her two assistants were outdoors on the patio with 13 children, as lunch was being served. All staff are cleared and associated.

Staff-child ratio was not met; license was out of ratio.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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Throughout the course of the investigation, interviews were conducted with four staff, the Reporting Party (RP), and one Adult; and documentation in the form of the Child Care Facility Roster, photos, and documentation of property records were obtained.

-Pertaining to the allegation that “Licensee is operating over capacity”:

The allegation refers to RP receiving photos of the children in care and there are 14 children, but none of them are school-age and RP knows that licensee cares for school-age children as well.

During the initial interviews conducted, three of the four staff denied ever having more than 14 children in care at a time. However, licensee said she may have been overcapacity one time when there was an overlap between a child being dropped off and another being picked up. When asked for the children’s schedules, licensee stated: 07:00-12:30 or 02:00-05:00 (after school), or 08:00-02:00 or 03:00-06:00 (after school) or 07:30-11:30 and that there are some who do just certain days. Licensee stated there are some full-time, some part=time, and some who drop in (every other week).

When asked to name the particular children they care for, one staff named exactly 14 children, another named 15 and another named 17.

As concrete schedules of children could not be provided, the allegation that “Licensee is operating over capacity” has been determined to be Unsubstantiated.This agency has investigated the complaint alleging that “Licensee is operating over capacity” and that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 102416.5 Staffing Ratio and Capacity. Based upon the evidence as presented above, the allegation has been determined to

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies are being cited for the allegation listed above.



-Pertaining to the allegation that “Licensee does not spend a sufficient amount of time in the childcare home”:

The allegation pertains to the fact that the Reporting Party noted that licensee arrives at the residence between 06:30-07:00 am and was not always present at pick up time, at around 05:30 pm.

Licensee’s daycare hours of operation are/were 06:00-06:00, though licensee says she does not accept children until 07:00 am, thus leaving one hour of being “open” unaccounted for. (As of January 1, 2022, licensee claims she changed them to 07:00-06:00, though CCL has not been notified of the change). According to Title 22, temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. If the facility is open 11 hours a day, licensee cannot, therefore, be absence for more than 2 hours and 12 minutes.

When asked for how long she could be gone for during a day, licensee stated that she did not know. When asked whether she ever leaves the residence during operating hours, she stated to go to lunch, drop off or pick up children, and that she is usually gone for about an hour. Two of the staff interviewed corroborated that licensee leaves to pick up lunch or for drop off or pick up; the third stated to go grocery shopping or pick up children.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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When asked how long it takes to drop off or pick up children or to pick up lunch, all three staff stated approximately one hour.

As it could not be definitively determined that licensee’s absence from the residence exceeds two hours and 12 minutes on a daily basis, the allegation that “Licensee does not spend a sufficient amount of time in the childcare home” has been determined to be Unsubstantiated.

This agency has investigated the complaint alleging that “Licensee does not spend a sufficient amount of time in the childcare home” and that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 102417 Operation of a Family Child Care Home. Based upon the evidence as presented above, the allegation has been determined to be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies are being cited for the allegation listed above.

-Pertaining to the allegation that “Child sustained unexplained injuries while in care”:

This allegation refers to a child (C1) who, on two separate occasions, sustained an injury to their mouth and then a bump on the head. On neither occasion were incidents reported to the parent nor to Community Care Licensing, as required. As C1 is not verbal, C1 could not be asked what had occurred.

According to the licensee, when asked about how C1 sustained the injury to their mouth, licensee showed the parent a video of C1 jumping off a table into the sand and said, “I think this

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
NARRATIVE
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is how (s/he) hurt (his/her) lip.” Licensee showed LPAs the video, which only shows C1 standing on a table and looking as though they were going to jump off of it.

According to the remaining three staff, C1 allegedly jumped off of the table and bit their lip, though it is unknown what actually happened, only that the child’s lip was bleeding.

When asked for photos or any other documentation of the injury sustained to the mouth of C1 and of the bump, no documentation was provided.

As C1 could not be interviewed and no documentation was provided as verification that C1 sustained an injury to their lip and a bump on their head on two separate occasions, the allegation that “Child sustained unexplained injuries while in care” has been determined to be Unsubstantiated.

This agency has investigated the complaint alleging that “Child sustained unexplained injuries while in care”and that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 102417 Operation of a Family Child Care Home. Based upon the evidence as presented above, the allegation has been determined to be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.



No deficiencies are being cited for the allegation listed above.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 33-CC-20211223112943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
VISIT DATE: 03/21/2022
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A Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Veronica Jimenez

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
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