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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364805560
Report Date: 10/03/2023
Date Signed: 10/03/2023 01:23:30 PM


Document Has Been Signed on 10/03/2023 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:CHRISPENS FAMILY CHILD CAREFACILITY NUMBER:
364805560
ADMINISTRATOR:CHRISPENS, ADRIANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 662-6954
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:14CENSUS: 3DATE:
10/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee CHRISPENS, ADRIANNATIME COMPLETED:
01:30 PM
NARRATIVE
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On 10-3-2023 at the above time, LPA Montoya arrived at the Chrispen FCC home to process LIC809D page which was not formulated during the inspection dated 9-27-2023. LPA met with licensee ADRIANNA CHRISPENS and assistant during visit. There were 3 children in care. LPA reviewed LIC809D for signing.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/03/2023 01:23 PM - 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: CHRISPENS FAMILY CHILD CARE
FACILITY NUMBER: 364805560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
1596.866(3)(b)

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1596.866 (3)(b) Licensees of family day care homes shall ensure that at least one staff member who has a current course completion card in pediatric first aid and pediatric CPR issued by the American Red Cross, the American Heart
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Licensee will complete and submit First Aid CPR for herself and assistant and sent it to LPA Steven Montoya via email: Steven.montoya@dss.ca.gov.
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Association, or by a training program that has been approved by the Emergency Medical Services Authority pursuant to this section and Section 1797.191 shall be onsite at all times when children are present at the facility, and shall be present with the children when children are offsite from the facility for facility activities. This requirement is not met as evidenced of records review. the licensee did not comply with the section cited above in [2] out of [2] CPR First Aid records (S1, S2) which poses a potential health, safety or personal rights risk to persons 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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2