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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845571
Report Date: 10/18/2021
Date Signed: 10/18/2021 03:11:13 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:ROBINSON BUCKNER FAMILY CHILD CAREFACILITY NUMBER:
334845571
ADMINISTRATOR:ROBINSON BUCKNER,JACQUELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 333-6261
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:14CENSUS: 5DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jackie Robinson BucknerTIME COMPLETED:
03:15 PM
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On 10/18/21 at 2:10PM, a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido to conduct children interviews in the course of another inspection at another facility. LPA was granted entry by Licensee, Jackie Robinson Buckner toured the facility, and took census.

An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to the Licensee; and the LPA observed the Notice of Site Visit form was posted. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC UPON REQUEST FOR THREE YEARS.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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