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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334816729
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:26:29 PM


Document Has Been Signed on 11/08/2023 12:26 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:DIAZ FAMILY CHILD CAREFACILITY NUMBER:
334816729
ADMINISTRATOR:DIAZ, MARICHEL & MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 805-2700
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:14CENSUS: 10DATE:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Marichel DiazTIME COMPLETED:
12:36 PM
NARRATIVE
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On November 8, 2023,upon arrival for a complaint investigation, children's files reviewed, revealed that three infants present at time of inspection did not have infant safe sleep plan LIC9227. Annual compliance inspection dated January 21,2022, revealed that licensee was obtaining the forms for infants in care at that time. During today's inspection, Licensee, Marichel Diaz stated she was unaware that she had to complete these forms for infants under 12 months in care and would have the parents complete the forms today and submit proof of correction to LPA Flores by 11/15/23.
see 809D for deficiencies

An exit interview was conducted, a copy of this report, 809D & appeal rights, along with a Notice of Site Visit was handed to licensee, Marichel Diaz.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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Document Has Been Signed on 11/08/2023 12:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501


FACILITY NAME: DIAZ FAMILY CHILD CARE
FACILITY NUMBER: 334816729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2023
Section Cited
CCR
102425(c)

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102425(c) An individual Infant Sleeping Plan (LIC9227) shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. This was not met as evidenced by….
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Licensee will obtain copies of infant safe sleep plan LIc9227 and submit proof of corrections to LPA Flores via email by 11/15/23.
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Based on record review and interview, licensee did not have LIc9227 for three infants in care at time of inspection. This poses a potential health, safety and personal rights 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: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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