334844715-7-17-2019-09-CC-JHUH-BE6PXX-20190717114303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334844715
Report Date: 07/17/2019
Date Signed: 07/17/2019 11:43:28 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	CORDOVA FAMILY CHILD CARE		FACILITY NUMBER:	334844715
ADMINISTRATOR:	GABRIELA CORDOVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(951) 396-0973
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	14	CENSUS: 8	DATE:	07/17/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	GABRIELA CORDOVA		TIME COMPLETED:	11:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On date and time noted, Licensing Program Manager (LPM) Dawn Parker and Licensing Program Analysts (LPAs) John Huynh and Otsanya Cameron conducted a Random Annual Inspection using the Inspection Tool as part of the Inspection Tool Pilot Project. This Inspection tool consists of a short staff interview; a review of both the physical plant, operation and records. The results of these reviews will be put into the standard inspection domain tools based upon this initial review, the inspection tool will determine whether a more comprehensive inspection is required into any one or more domains (you may refer to the Pilot Operations Program Manual located on the ccld.ca.gov website under Inspection Process Project and Child Care for more details). Following this inspection, the Licensee will be asked to sign the report acknowledging receipt. This report will be uploaded onto the transparency website. All appeal rights will apply to this report and explained to the licensee or representative during the exit interview. The Licensee will be sent a survey to provide their feedback on this inspection tool and this process. This visit was also conducted with Licensing Program Manager (LPM) Dawn Parker who completed the inter-rater reliability inspection. A prior inspection was conducted on 07/16/2019. Present during that visit were the Licensee, Gabriella Cordova, Assistant Jacqueline Ramirez and Assistant Guadalupe Ramirez. CONTINUE ON LIC 809-C

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC9099D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT).

A Confidential Names List was completed and provided to the applicant.

A copy of this report was provided to the applicant on this date and must be made available to the public upon request for the next 3 years.

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)(C)

Physical Plant - Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (C) Ammunition shall be stored and locked separately from firearms.
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: On 07/16/2019, the licensee could not prove that fire arms and ammunition in the home were stored and locked separately. The storage location of the fire arms were locked but could not demonstrate that the fire arms and ammunition were locked separately. This poses a potential risk to the Health and Safety of children in care.
	POC Due Date: 07/17/2019
	Plan of Correction
1 2 3 4	During today's inspection, the Licensee was able to show that the ammunition and fire arms were locked separately.

Type B

Section Cited

CCR

102416.1(a)

Facility Administration - Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information:
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: On the 07/16/2019 inspection, the licensee did not have a employee file for Staff S1. This poses a potential risk to the health and safety of the children in care. This poses a potential risk to the Health and Safety of children in care.
	POC Due Date: 08/19/2019
	Plan of Correction
1 2 3 4	The licensee has agreed to submit a copy of Staff S1's completed file to the Department by 08/19/2019. John.Huynh@DSS.CA.GOV

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: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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The following was reviewed with the licensee(s):
- SB792 – Immunization requirements for staff, volunteers, effective September 1, 2016 – In accordance with California Health and Safety Code Section 1597.622(a)(1) - a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination or they may provide a statement declining the vaccination. If employees/volunteers are receiving the influenza vaccination, they must do so between August 1 and December 1 of each year.
- AB2231 (2016) – Increased Civil Penalties, effective July 1, 2017 – For failing to correct a violation the civil penalty is increased to $100 per day for EACH violation until corrected; For failing to correct a repeated violation the civil penalty is increased to $250 immediately assessed , and $100 per day afterwards for EACH repeated violation until corrected; For a Zero Tolerance violation the civil penalty is increased to $500 immediately assess, and $100 per day for EACH violation after that until corrected; For any repeated Zero Tolerance violation the civil penalty is increased to $1,000 immediately assess, and $100 per day afterwards for EACH repeated violation until corrected.
NOTE: Repeat violations are defined as a violation of a previously cited statutory or regulatory Section and/or subsection within 12 months prior.
- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov
- SB420 Effective January 1, 2017 – State summary criminal history information – Information provided to the Department shall include sentencing information.
- AB2370 – Effective January 1, 2019 – Lead Poisoning – providers are required to provide a lead toxicity prevention handout to parents/guardians of newly enrolled and newly reenrolled children with information on risks and effects of lead poisoning; blood lead testing recommendations and requirements; and options for obtaining blood lead testing, including free and/or discounted testing. There will be a training component of this added to the Preventative Health Training beginning July 1, 2020.

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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Present during today’s visit were the Licensee, Gabriella Cordova, assistant Jacqueline Ramirez, husband Andrew Perez. Licensing Program Analyst (LPA) John Huynh toured the facility, inside and out, records were reviewed, and the following was observed:
Normal days and hours of operation are: Monday thru Friday, 6:00AM to 6:00PM.
OFF-LIMIT AREAS INCLUDE: The complete backyard and all four bedrooms.
The inspection consisted of reviews of the following domains:
· Physical Plant
· Care and Supervision
· Facility Administration
· Records
· Staffing Ratio and Capacity
· Personal Rights
The inspection found the facility to be in compliance in these domains except as noted on the LIC809D.
· LICENSEE UNDERSTANDS ALL GUNS, WEAPONS AND AMMUNITION MUST BE KEY-LOCKED SEPARATELY AND MADE INACCESSIBLE PER TITLE 22 REGULATIONS.
· There are no bodies of water as of this date. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Pediatric CPR and First Aid Card - expire on 12/31/2020 Gabriella Cordova
· Health & Safety Certificate - completed on 10/15/2017
· All providers, including the licensee, assistant and substitute providers have completed mandated reporter training – Staff S1 did not have her mandated reporter completed.

CONTINUE ON LIC 809-C

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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·The licensee understands and shall permit the Department to inspect the family child care home and to privately interview children or staff to determine compliance with or to prevent violations of family child care laws or regulations.
· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed.
Resident and/or staff records reviewed on 07/16/2019 indicated that NOT all adults who require caregiver background checks had received all required clearances or exemptions.
· The Licensee is operating within her licensed capacity and ratio during this inspection.
· Facility is not currently providing IMS at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514- 0383 (TTY) and link to publication : Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
· For more information on SIDS and Safe Sleep Environments, please visit:
California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Risk-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep

CONTINUE ON LIC 809-C

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)

Facility Administration - Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: On the 07/16/2019 inspection, LPM and LPAs observed S1 working at the facility. S1 stated she had been working at the facility for more than five (5) days and did not have a fingerprint clearance. This poses an immediate risk to the health and safety of children in care. THIS VIOLATION RESULTS IN A CIVIL PENALTY OF $500.00.
	POC Due Date: 07/18/2019
	Plan of Correction
1 2 3 4	The Licensee has agreed to have Staff S1 go and have her LIVESCAN completed and will submit the required documentation: Proof of LIVESCAN, LIC 9182 Criminal Background Transfer, LIC 508 Criminal Record Statement with a copy of her ID or drivers license to the Department by 07/18/19. John.Huynh@DSS.CA.GOV

Type A

Section Cited

CCR

102416.5(d)(1)

Staffing Ratio and Capacity - Staffing Ratio and Capacity

(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: On 07/16/2019, LPM and LPAs observed 14 children in care, four of the children were infants. This poses an immediate risk to the health and safety of children in care. This poses an immediate risk to the health and safety of children in care.
	POC Due Date: 07/18/2019
	Plan of Correction
1 2 3 4	The Licensee has agreed to submit a Plan of Action statement to the Department by 07/18/2019 on how she will prevent this from happening again. John.Huynh@DSS.CA.GOV

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: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

LIC809 (FAS) - (06/04)

Page: 7 of 11

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Records - Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: On the 07/16/2019 inspection, the licensee could not provide complete children's files for Child C5 & C6. This poses a potential risk to the health and safety of children in care. This poses a potential risk to the Health and Safety of children in care.
	POC Due Date: 08/19/2019
	Plan of Correction
1 2 3 4	The licensee has agreed to submit proof of Child C5 and C6's completed file to the Department by 08/19/2019. John.Huynh@DSS.CA.GOV

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

LIC809 (FAS) - (06/04)

Page: 8 of 11

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – In accordance with California Health and Safety Code Section 1596.8662 – requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. Existing licensees must meet requirements by March 30, 2018. New employees shall have 90 days to complete training as required. This training requirement may be directly met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/ and are provided in English and Spanish. If no training is made available in a required person’s primary language then those persons shall be exempt from this requirement
- Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited
- The applicant is urged visit the U.S. Consumer Product Safety Commission webpage at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled
- Once licensed, the Notice of Site Visit will be posted in a prominent location at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
- Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov.
CONTINUE ON LIC 809-C

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

LIC809 (FAS) - (06/04)

Page: 9 of 11

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 07/17/2019

NARRATIVE

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- Please subscribe by sending an email to childcareadvocatesprogram@dss.ca.gov and requesting to be added to the email list to receive Department updates. They will be sent directly to your e-mail account. Updates can also be accessed through www.ccld.ca.gov
- The Duty Officer is available to answer questions Monday – Friday at 1-844-LET-US-NO (1-844-538-8766).

During the exit interview, the LICENSEE, Gabriella Cordova confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

See LIC809D for cited deficiencies.

Appeal rights were discussed and a copy of this report was provided to the licensee on this date.

A civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and TB Screen and have your child submit for LIVESCAN background clearance. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit the LIC508, TB screening and obtain a background clearance through LIVESCAN.

CONTINUE ON LIC 809-C

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John Huynh	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019

LIC809 (FAS) - (06/04)

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