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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019677
Report Date: 03/15/2023
Date Signed: 03/15/2023 05:00:44 PM


Document Has Been Signed on 03/15/2023 05:00 PM - 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:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
198019677
ADMINISTRATOR:LORENA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 427-4708
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:14CENSUS: 2DATE:
03/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Lorena Martinez, LicenseeTIME COMPLETED:
05:09 PM
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On Wednesday, March 15, 2023 at 1:23 p.m., Licensing Program Analyst (LPA) Mayra Rivera conducted a Case Management inspection at the above facility to follow up on the self reported incident that occurred on Tuesday, March 14, 2023 in child falling and sustaining an injury. LPA met with Licensee Lorena Martinez, who guided the LPA on a tour of the facility. Two children present during this visit.

LPA Rviera interviewed licensee and child #3 .and obtained copies of relevant documents.

Base on the information provided and documents received in regards the incident that occurred on March 14, 2023, further investigation is needed.

Upon receipt, Notice of Site Visit shall be posted for thirty (30) consecutive days where the parent/guardian of children enter and exit the facility Failure to maintain posting as required will result in a $100 civil penalty.

Exit interview conducted with Licensee, Lorena Martinez and appeal rights were provided and explained.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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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