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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400286
Report Date: 08/18/2021
Date Signed: 08/18/2021 01:19:11 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:MOORE FAMILY CHILD CAREFACILITY NUMBER:
198400286
ADMINISTRATOR:CHRYSTAL MOOREFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 362-9727
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Chrystal MooreTIME COMPLETED:
01:25 PM
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Licensing Program Analyst Warren Birks conducted a Case Management inspection. LPA met with Licensee Chrystal Moore upon arrival. The Licensee indicated that she is requesting to go inactive for personal reasons. LPA informed Licensee regarding the inactive process. Licensee submitted an inactive form requesting to go inactive from August 18, 2021 to September 30th, 2021.

LPA informed Licensee to contact us if she wishes to return to active status sooner than September 30, 2021.

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

Exit interview was conducted with Licensee, Chrystal Moore.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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