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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844398
Report Date: 11/16/2020
Date Signed: 11/16/2020 09:02:05 AM

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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
334844398
ADMINISTRATOR:YANIRA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 564-2696
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:14CENSUS: 0DATE:
11/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Yanira LopezTIME COMPLETED:
09:00 AM
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A Case Management Visit is being conducted in response to the receipt of an Unusual Incident (UIR) from the facility. Initial visit was 11/6/20. The Unusual Incident Report was received by the Licensing Agency on November 2, 2020. It indicates on the Unusual Incident Report, dated 11/1/20, it was reported a child complained of pain on the left arm after coming off the jumper. From interviews conducted, the child was playing on the jumper and came down the slide and started to cry. The child was complaining of pain on left arm. The Adult tended to the child and the Licensee applied first aid to the child's arm. The parent was notified and the child received medical attention. LPA conducted interviews. Based on the information gathered, no violations have been identified.

An exit interview was conducted via Face-time, LPA Jackson provided the applicant with a copy of this report via email, LPA asked the Applicant to acknowledge receipt of the email. An electronic “Read receipt” was also attached. The electronic read receipt of the emailed report acknowledges receipt of this report. A copy of this report was emailed to the Applicant during this Tele-inspection on November 16, 2020.

A copy of this report was left with the Licensee and a copy must be made available upon request, to the public, for 3 years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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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