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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014104
Report Date: 03/26/2021
Date Signed: 04/15/2021 02:59:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SANDOVAL FAMILY CHILD CAREFACILITY NUMBER:
198014104
ADMINISTRATOR:SANDOVAL, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 876-6573
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:14CENSUS: 11DATE:
03/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
06:16 PM
MET WITH:Maria SandovalTIME COMPLETED:
07:45 PM
NARRATIVE
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This Case Management tele-inspection was conducted by Licensing Program Analyst (LPA) Warren Birks via teleconference due to COVID-19 and precautionary measures. LPA met with Licensee Maria Sandoval who along with an assistant, were providing care for 11 children. This tele-inspection is regarding an incident that took place on March 4, 2021.

On March 11, 2021, Licensee Sandoval informed LPA that on March 4, 2021 she received a visit from a DCFS Social Worker in regards to a child that was injured off-site (not at the childcare facility). The DCFS worker informed Licensee Sandoval that her facility was not involved however, he wanted to ask questions regarding the child.

LPA informed Licensee that she was required to report the Social Worker visit to Child Care Licensing as it qualifies as an unusual incident. Licensee Sandoval indicated that she didn't know the incident had to be reported because the injury did not happen at her daycare. The Licensee is cited for "reporting requirements" as Title 22 Regulations require unusual incidents be reported to Community Care Licensing within 24 hours (followed up with a written report within 7 days).

Note: The Licensee submitted a detailed written incident report regarding the March 4, 2021 incident.

Exit interview conducted with Licensee Sandoval via teleconference. This report along with a copy of the appeal rights will be sent to the Licensee via email with a read receipt to confirm receipt of the report and to act as the signature on the report.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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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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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SANDOVAL FAMILY CHILD CARE
FACILITY NUMBER: 198014104
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2021
Section Cited

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Reporting Requirements: The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.

Any unusual incident or child absence that
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threatens the physical or emotional health or safety of any child."

This requirement was not met as evidenced by: Licensee did not report a 3/4/21 visit by a DCFS Social Worker regarding an injury off site (not at the daycare). This is a potential risk to 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: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2021
LIC809 (FAS) - (06/04)
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