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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844328
Report Date: 06/21/2019
Date Signed: 06/21/2019 02:36:12 PM

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:SHAW-HOWARD FAMILY CHILD CAREFACILITY NUMBER:
334844328
ADMINISTRATOR:SHAW-HOWARD, LATEEFAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 315-2827
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:14CENSUS: 5DATE:
06/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lateefah Shaw-HowardTIME COMPLETED:
02:45 PM
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A case management visit is being conducted in response to the receipt of an Unusual Incident Report (UIR) from the facility. The Unusual Incident Report was received on 6/13/19. LPA met with the Licensee, Lateefah Shaw-Howard. LPA conducted interviews. LPA will return to the facility at a later date to conclude the investigation.

An exit interview was held and a copy of this report was provided at time of visit.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 784-4200
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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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