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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018824
Report Date: 05/17/2019
Date Signed: 05/17/2019 12:21:31 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:WATTS FAMILY CHILD CAREFACILITY NUMBER:
198018824
ADMINISTRATOR:MIRTA / LARRY WATTSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 335-8052
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:14CENSUS: 4DATE:
05/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Mirta and Larry WattsTIME COMPLETED:
11:58 PM
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Ana Chico, Licensing Program Analyst (LPA) conducted an unannounced Case Management inspection for the purpose of following up on an incident report dated 5/16/19. LPA met with with licensee, Mirta and Larry Watts. Two children were present.

On this date, LPA toured the home. According to licensee, subject chid #1 was playing with another child on the large carpet. Both children were holding hands when child #2 pulled on the hand of child #1 who subsequently fell forward and hit his head on one of the shelves use for the day care. Child suffered a bump to the forehead. Licensee provided first aid and contacted parent. Parent took child #1 to the doctor. According to parent, child did not suffer a concussion and was well to return to the day care.
Licensee was present when the incident occurred and met all reporting requirements. Based on the information obtained, no deficiencies are being cited in accordance to Title 22 California Code of Regulations.
Exit interview conducted. Appeal rights discussed. Notice of Site Visit provided an must be posted for 30 days.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-2956
LICENSING EVALUATOR NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
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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