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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843071
Report Date: 11/03/2022
Date Signed: 11/03/2022 10:16:36 AM


Document Has Been Signed on 11/03/2022 10:16 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 STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:KING FAMILY CHILD CAREFACILITY NUMBER:
334843071
ADMINISTRATOR:WENDY KINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 567-8839
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:14CENSUS: 10DATE:
11/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Wendy KingTIME COMPLETED:
10:30 AM
NARRATIVE
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On the date and time listed, Licensing Program Analyst (LPA) Nasha King arrived at the facility to conduct an inspection for a separate purpose. This Case Management Visit is being conducted to address a separate issue that was discovered while gathering information during a complaint investigation (Complaint Control Number 10-CC-20221003170152). LPA toured the facility, took census, and spoke with the Licensee regarding the Department’s Reporting Requirements.

LPA King learned that on 09/19/2022 a child, while in the Licensee’s care, suffered an injury that required medical attention. The Licensee failed to report the incident to Community Care Licensing (CCL), and the Licensee disclosed the incident only after LPA King made contact with her on October 10, 2022, while conducting an initial 10-day inspection at the residence. LPA verified that a report was not made via telephone or fax the next business day nor was a written report submitted to CCL within seven days following the incident. As of 11/03/2022, the Department still has not received an Unusual Incident Report (UIR) for the incident that occurred on 09/19/2022.

The facility was found to be in violation of Title 22 Regulations.

See LIC 809D for deficiency cited.

An exit interview was conducted, and this report was reviewed with the Licensee, Wendy King. A copy of the report was also provided.

Appeal rights were discussed and provided during the exit interview.

A Notice of Site visit was given, and the Licensee understands that it must remain posted for 30 days.
SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Nasha KingTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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Document Has Been Signed on 11/03/2022 10:16 AM - 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: KING FAMILY CHILD CARE
FACILITY NUMBER: 334843071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited

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Reporting Requirements – The licensee shall report to the Department any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family childcare home.
This requirement was not met as evidenced by:
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A child was injured while in care at the facility on 09/19/2022 and the licensee did not report the incident to licensing within 24 hours by phone or a written LIC 624 Unusual Incident Report within 7 days of the incident occuring. This poses a potential risk to the Health and Safety of 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: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Nasha KingTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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