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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364803073
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:52:59 AM

COMPREHENSIVE INSPECTION
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:CAMPOS FAMILY DAY CAREFACILITY NUMBER:
364803073
ADMINISTRATOR:CAMPOS, CHARLENE & LUISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 862-9324
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:14CENSUS: 8DATE:
10/16/2019
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Charlene & Luis CamposTIME COMPLETED:
11:05 AM
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Licensing Program Analysts (LPAs) Taadhimeka Zeigler and James Wilkerson returned to the facility for the continuation of an annual inspection. Initial visit was conducted on 10/04/2019. Upon arrival, LPAs met with Licensees, Charlene & Luis Campos, the purpose of the visit was discussed. Census was taken.

During this inspection, LPA reviewed staff and children records, children's roster, documentation of fire/emergency drills, and carbon monoxide detector.

Exit interview was conducted with Charlene & Luis Campos, Notice of Site Visit was issued and must be posted for 30 days. LPAs verified posting. A copy of this report was provided to the Licensees.

This report must be made available at the facility for 3 years for public review upon request.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 680-6745
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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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