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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360918948
Report Date: 01/13/2022
Date Signed: 02/22/2022 09:19:32 AM


Document Has Been Signed on 02/22/2022 09:19 AM - It Cannot Be Edited

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:MIELEWCZYK FAMILY CAREFACILITY NUMBER:
360918948
ADMINISTRATOR:MIELEWCZYK, KRYSTYNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 875-0560
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY:12CENSUS: 3DATE:
01/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Krystyna MielewczykTIME COMPLETED:
02:35 PM
NARRATIVE
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On this date and time, Licensing Program Analyst (LPA) Laura Mejorado arrived at the facility to conduct an inspection for a separate purpose. LPA toured the facility, took census and verified staff's criminal record clearances and association to facility.

See LIC809D for deficiency cited per California Code of Regulations Title 22, Division 12.

Exit interview conducted and report was reviewed with Licensee Krystyna Mielewczyk.

A copy of this report must be made available to the public for 3 years.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224 form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224)

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Laura MejoradoTELEPHONE: 951-782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022
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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Document Has Been Signed on 02/22/2022 09:19 AM - It Cannot Be Edited

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: MIELEWCZYK FAMILY CARE
FACILITY NUMBER: 360918948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2022
Section Cited

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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:(1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirment was not met by:
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Based on review of records, it was found that R#1 is living in the home with no criminal record fingerprint clearance or association to the facility. This poses an immediate health, safety, and personal rights risk to 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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Laura MejoradoTELEPHONE: 951-782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022
LIC809 (FAS) - (06/04)
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