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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304204493
Report Date: 03/26/2019
Date Signed: 09/11/2019 04:16:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ALSOBROOK, MONICAFACILITY NUMBER:
304204493
ADMINISTRATOR:ALSOBROOK, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 669-5483
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:14CENSUS: 10DATE:
03/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Monica AlsobrookTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) S. Hawkins made an unannounced visit to the facility for a case management meeting. LPA met with Licensee Monica Alsobrook and toured the home. Present in the home was licensee and adult assistant Leti Lomeli who has also been fingerprint cleared. Total census observed was 10 children present (4 infants, and 6 preschoolers ). A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 4/9/18 law enforcement visited the facility and licensee failed to report incident to the Licensing office.

Exit interview was conducted, and report was reviewed and discussed. Notice of Site Visit was posted during the visit. The licensee was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12 Section 102416.2(b), were observed: see LIC 809D.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ALSOBROOK, MONICA
FACILITY NUMBER: 304204493
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/05/2019
Section Cited

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 Reporting Requirements. The licensee shall report to the Department
any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A)
through (b)(1)(C) that occur during the operation of the family child care home.
This requirement was not met as evidenced
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by Licensee failed to report an incident of law enforcement visiting the facility. This is a potential threat to the children's safety.
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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: Judy HansonTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2019
LIC809 (FAS) - (06/04)
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