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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019677
Report Date: 06/29/2023
Date Signed: 06/29/2023 11:56:56 AM


Document Has Been Signed on 06/29/2023 11:56 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:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
198019677
ADMINISTRATOR:LORENA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 427-4708
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:14CENSUS: 5DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lorena Martinez, LicenseeTIME COMPLETED:
11:58 AM
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On Thursday, June 29, 2023, at 9:50 a.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 March 14, 2023, in child sustaining an injury and transported to the hospital by ambulance. LPA met with Licensee, Lorena Martinez. During this visit, LPA Rivera observed 5 children present.

Based on Investigation Bureau (IB), information provided, and documents received in regards the incident that occurred on March 14, 2023, the facility followed emergency medical procedures and medical report revealed child had an underlying medical condition which may have contributed to the incident. Therefore, the allegation that the child sustained an injury in care due to neglect/lack of care and supervision by facility when the child fell while in care, determined there to be no violation of Tittle 22.

During this visit, LPA Rivera had a conversation with Licensee in regards transporting children in her vehicle. LPA informed Licensee, before transporting children, parent’s need to be made aware and give authorization prior to transporting their child. Licensee stated she has one care seat she utilizes and parent of child #1 leaves behind a car seat. Licensee stated, both parents of children #1 and #2 are aware and gave verbal authorization to transport their children. LPA explained and provided form PUB 269 California Child Passenger Safety Law.


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: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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