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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844529
Report Date: 09/27/2019
Date Signed: 09/27/2019 11:53:29 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:MOORE FAMILY CHILD CAREFACILITY NUMBER:
334844529
ADMINISTRATOR:MOORE JULIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 489-6025
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:14CENSUS: 6DATE:
09/27/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Julie MooreTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Jackson arrived at the facility for a Complaint Investigation and observed the following deficiency. The Licensee failed to report the incident that occurred on 4/15/19.

A child #1 pushed a door and locked child #2 in a bedroom. The door was key-locked from the inside. The Licensee called 911 and the Police went through the bedroom window and let the child out.

See 809D.

An exit interview was held with Licensee, Ms. Moore. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
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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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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 334844529
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2019
Section Cited

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REPORTING REQUIREMENTS. The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm).
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This Requirement was not met as evidenced by: A child #1 pushed a door and locked child #2 in a bedroom. The Licensee called 911 and the Police went through the bedroom window and let the child out.
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This poses an potential risk to the Health, 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: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2019
LIC809 (FAS) - (06/04)
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