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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313517
Report Date: 05/23/2022
Date Signed: 05/24/2022 08:05:38 AM


Document Has Been Signed on 05/24/2022 08:05 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:ORNELAS, JESSICAFACILITY NUMBER:
304313517
ADMINISTRATOR:ORNELAS, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 335-1252
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:14CENSUS: 5DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jessica Ornelas, LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) P. Rivas conducted an unannounced annual inspection, LPA was assisted by Asst A. Jimenez and later was met by licensee, Jessica Ornelas. Present during visit 5 toddlers and one assistant. Licensee was operating within the licensed capacity as specified on license. Licensee reports there are 2 adults and 3 children living in the home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day can assessed . Facility Day care hours are 3am-midnight Mon-Sunday.

LPA conducted physical plant tour, staff interview and staff file reviews. Due to time constraints the annual inspection will be commenced at a later date.
During today's visit no deficiencies were noted under the California Code of Regulations Title 22 Division 6.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their
signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. Notice of Site of site visit was provided, licensee was reminded to keep Notice of Site visit posted for 30 days otherwise a $100.00 civil penalty will be assessed.

exit interview completed.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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