<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313087
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:24:12 PM


Document Has Been Signed on 06/07/2022 02:24 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, 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: 0DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lizeth Vivar, licensee TIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/07/2022, 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 licensee Lizeth Vivar.
During the inspection the facility had no daycare 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 on 05/12/2022, to investigate into this unusual incident. During the course of the investigation, LPA Nguyen interviewed staff members related to the reported unusual incident. There were no disclosures made by staff. No children were interviewed, due to being unqualified. There are no safety concern with the facility from interviewed parent.

Based on the interview conducted and observation, it was determined no violation of Title 22 regulations. 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 posted. 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 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. First level appeal is to Regional Manager, address is above on the report.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Tina NguyenTELEPHONE: (714) 292-2922
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1