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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364806517
Report Date: 02/24/2020
Date Signed: 02/24/2020 05:59:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
364806517
ADMINISTRATOR:HERNANDEZ, ELAINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 885-1511
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:14CENSUS: 4DATE:
02/24/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Elaine Hernandez Licensee TIME COMPLETED:
06:09 PM
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License Program Analyst (LPA) Steven Montoya contacted licensee for purposes of inspecting the Immunization records for the licensee and children review dated 02-03-2020. At the time of the inspection, licensee was unable to provide records upon inspection.

LPA was able to review the deficiencies with licensee. Licensee was able to obtain the updated records for inspections. List of deficiencies:

1. 1597.541 (b) Age-appropriate immunization requirements; adoption of regulations (b) All family day care homes for children shall maintain evidence that enrolled children have met the age-appropriate immunization requirements adopted pursuant to this section.

2. 597.622 Employee and Volunteer Immunization. (c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.

Provided copy of immunization laws.
Proof of Clearance was generated dated 02-24-2020.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 568-8932
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2020
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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