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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019959
Report Date: 05/04/2023
Date Signed: 05/07/2023 10:35:04 PM


Document Has Been Signed on 05/07/2023 10:35 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:MACK FAMILY CHILD CAREFACILITY NUMBER:
198019959
ADMINISTRATOR:MYESHA MACKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 812-3674
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:14CENSUS: 7DATE:
05/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Myesha Mack, LicenseeTIME COMPLETED:
03:05 PM
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 CONSISTENCY CHECK
On 05/04/23, Licensing Program Analyst (LPA) Susann Sanchez conducted a POC inspection to follow up on the citations that were cited on 04/04/23 and 04/20/23. Due to technical difficulties LPA could not provide a printed copy of the LIC 809 report. Copy of report will be provided at a later date.

LPA determined the following:
- Licensee submitted the a schedule via email on 04/20/23
- LPA observed (7) children's files, all having the Acknowledgment of Recepit (LIC 9227)
- LPA observed Notice of Site Visit and 809 report dated 04/04/23 and 04/20/23.

Therefore, based on LPA record review and observations POCs has been cleared. Exit interview was provided with Licensee Myesha Mack. Notice of Site Visit and Appeal Rights were given.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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