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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019679
Report Date: 04/29/2019
Date Signed: 04/29/2019 12:13:15 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:ANDRADE FAMILY CHILD CAREFACILITY NUMBER:
198019679
ADMINISTRATOR:ESTELA ANDRADEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 421-1662
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:14CENSUS: 1DATE:
04/29/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Estela AndradeTIME COMPLETED:
12:20 PM
NARRATIVE
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This case management inspection was conducted by Complaint Specialist - LPA Karen Chambers, who met with Estela Andrade Licensee.

During this inspection the following was observed and cited in accordance with Title 22, California Code of Regulations:

1. The Licensee was made aware on 3/9/19 by a parent that their child sustained an injury with unusual bruising while in the care of the Licensee on or about 3/8/19 and Licensee failed to report as required.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. This notice shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted with the Licensee, during which appeal rights were explained. A copy of the appeal rights (LIC9058 01/16) were provided. The Licensee’s signature on this report acknowledges receipt of her rights.

SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)981-3368
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019
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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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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANDRADE FAMILY CHILD CARE
FACILITY NUMBER: 198019679
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2019
Section Cited
CCR
102416.2(b)
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Reporting requirement: The licensee shall report to the Department any unusual incident or child absence that threatens the physical or emotional health or safety of any child." that occur during the operation of the family child care home. On 3/9/19 the Licensee was made aware of child's sustaining an injury with
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Per Licensee: I'm aware of the form and didn't think I should have reported. I will report what was said and send to the Department.
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unusual brusing while in care on or about 3/8/19. The licensee failed to report this within the required 24 hours or the written with in the required 7 days.
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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: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Karen ChambersTELEPHONE: (323)981-3368
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019
LIC809 (FAS) - (06/04)
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