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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312394
Report Date: 10/23/2019
Date Signed: 10/23/2019 11:43:11 AM

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:HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTOFACILITY NUMBER:
304312394
ADMINISTRATOR:AREVALO ESPERANZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 415-9125
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:14CENSUS: 4DATE:
10/23/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Assistants, Magaly Lopez and Ariadna JimenezTIME COMPLETED:
12:00 PM
NARRATIVE
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A case management inspection was conducted by Licensing Program Analyst (LPA) Port due to deficiency observed during today's inspection.

LPA met with Assistant, Ariadna Jimenez who granted LPA entrance to the faciliy. There was 1 infant and 2 preschool age children present with Assistants, Magaly Lopez and Ariadna Jimenez upon arrival. Assistant, Whitny Estrada arrived at approximately 10:45 AM. Assistants Ariadna Jimenez and Whitny Estrada departed at 10:55 PM to pick up school age children. An additional preschool child arrived at 11:30 AM.

A review of adult records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. However staff member, Whitny Estrada has not been associated to the facility and has been present since 10/15/2019. The licensee was interviewed via telephone and stated she mailed the association documents to the licensing office on 10/17/2019. Based on record review there was no proof of mailing.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed and cited during today's inspection: Criminal Record Clearance 102370(d)(2) (see LIC 809D). A civil penalty of $500.00 was assessed.



Exit interview was conducted with Assistant, Magaly Lopez. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Facility representative 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. Appeal rights provided and explained. The facility representative was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. Facility representative was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO
FACILITY NUMBER: 304312394
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2019
Section Cited

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Criminal Record Clearance 102370(d)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 102370(j). This requirement was not met as evidenced by:
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Based on interviews and record review conducted Assistant Whitny Estrada has been present in the facility since 10/15/2019 and has not been associated to the facility. The licensee stated association documents were sent however there was no proof available. This poses a potential safety risk to children in care.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2019
LIC809 (FAS) - (06/04)
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