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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842133
Report Date: 03/21/2024
Date Signed: 03/21/2024 11:14:45 AM


Document Has Been Signed on 03/21/2024 11:14 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:PAVLICH FAMILY CHILD CAREFACILITY NUMBER:
334842133
ADMINISTRATOR:PAVLICH, AMANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 314-8764
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:14CENSUS: 6DATE:
03/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Amanda Pavlich, LicenseeTIME COMPLETED:
11:24 AM
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Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a Case Management-Incident inspection for the purpose of concluding the investigation on an Unusual Incident Report from the facility. At the time of the inspection, LPA toured the facility, took census, and interviews were conducted. Present during the inspection was Tamara Pavlich, Assistant.

Based on information gathered, the facility acted appropriately and no violations have been identified at this time. The Licensee discussed the incident with the Authorized Representative and reported the incident to Licensing in a timely manner.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee, Amanda Pavlich.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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