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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313087
Report Date: 05/12/2022
Date Signed: 05/19/2022 10:26:33 AM


Document Has Been Signed on 05/19/2022 10:26 AM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:VIVAR, LIZETHFACILITY NUMBER:
304313087
ADMINISTRATOR:VIVAR, LIZETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 326-7790
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:14CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH: Staff Cindy Contreras;
Licensee Lizeth Viva		TIME COMPLETED:
11:15 AM
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On 05/12/2022, Licensing Program Analyst (LPA) Nguyen conducted a case management investigation for the incident that the facility self-reported to licensing office on 05/10/2022. LPA Nguyen met with facility staff Cindy Contreras; licensee Lizeth Viva came 10 mins later. Licensee was dropping off her child at school.
During the inspection the facility had 2 staff members and 6 children present. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearances or exemptions and a child abuse index clearance.
The inspection was conducted in response to an Unusual Incident Report received on 05/10/2022, in which on 05/10/2022 at 5:52 PM, parent #1 (See Confidential Names List LIC811) had reported to licensee that child #1 got an injury on the back. Per licensee, nothing has happened while under the facility care, child #1 had a great day and the only time the child cried was during drop off.
Licensee then reported the incident to Licensing in a timely fashion, compliant with reporting requirement regulations. An inspection was conducted today, 05/12/2022, to investigate into this unusual incident. During the course of the investigation staff and child related to the reported unusual incident were interviewed, a physical plant inspection was conducted, and census of children was taken.

Due to insufficient information at this time the Department will continue the investigation into this unusual incident report and will provide updates. No deficiencies were observed at the time of the visit. The facility was found to be in compliance with Title 22 regulations during today inspection.

Exit interview was conducted. The Notice of Site Visit was not posted due to tele-investigation Covide-19 State of Emergency. Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) will be provided through email and their signatures on this form acknowledges receipt of these rights. Report was discussed and reviewed. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Tina NguyenTELEPHONE: (714) 292-2922
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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