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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018858
Report Date: 12/08/2021
Date Signed: 12/08/2021 11:31:31 AM

Document Has Been Signed on 12/08/2021 11:31 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:FELIX MEDINA FAMILY CHILD CAREFACILITY NUMBER:
198018858
ADMINISTRATOR:LUZ FELIX MEDINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 584-4062
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Luz Felix Medina, LicenseeTIME COMPLETED:
11:50 AM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) A. Lucero to address an Unusual Incident Report that was received in the licensing office on 09/27/2021. LPA met with Licensee Luz Felix Medina.

On 09/27/2021, child #1 fell ill due to abdominal pain at the day care and was taken to the hospital. Per assistant, parent was notified of the child falling ill via telephone and accompanied the child to the hospital. Per assistant, parent stated that it was most likely something the child ate the night before that did not sit well with the child. Child returned to facility within two days with no restrictions.

Based on all information obtained on this date, and interviews conducted, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident and most like due from something the child ate the night before while in care with parents. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

There were no deficiencies observed in regards to today's visit. Exit interview, copy of report was given. Appeal rights were issued and discussed.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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