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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019934
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:06:41 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
198019934
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 8DATE:
10/01/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Hernandez, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced case management inspection to the above facility on 10/1/21 at 11:30 AM. LPA met with Maria Hernandez, Licensee, who guided analysts on a tour of the facility. The purpose of this inspection is to follow-up on a request for a capacity increase.

There were eight children present upon arrival. Also present during inspection was Staff One (S1), facility assistant. During inspection LPA confirmed correction made to the in-ground pool gate. LPA observed self-latch device has been moved up measuring two inches from the top of the gate, which is in compliance with Title 22. LPA observed that a new spring on the hinge of the self-latching device has been replaced. LPA tested and confirmed that when pool gate is opened (away from pool), the gate does automatically close and latch on its own.

Based on today’s observation a capacity increase will be granted upon Licensing Program Manager (LPM) Approval.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Maria Hernandez, Licensee, including, but not limited to Appeal Procedures and Appeal Right
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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