364807680-11-17-2021-09-CC-EJOS-C8UT5D-20211117132521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364807680
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:25:50 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:	GEORGE FAMILY CHILD CARE		FACILITY NUMBER:	364807680
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	11/17/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Yvonne George, Licensee		TIME COMPLETED:	01:34 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	The Licensee has applied to increase her capacity to that of a Large Family Child Care Home. Licensing Program Analyst (LPA) Elyse Jones toured the facility, inside and out, records were reviewed and the following was observed: · Normal days and hours of operation are: Monday-Friday, 6:00AM-6:00PM · OFF-LIMIT AREAS INCLUDE: All of upstairs, Garage, Pantry, Living Room, and left side yard when facing the yard · Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the licensee during this inspection. · All hazardous items are NOT inaccessible · Toxins are NOT locked · LICENSEE UNDERSTANDS ALL GUNS, WEAPONS AND AMMUNITION MUST BE KEY-LOCKED SEPARATELY AND MADE INACCESSIBLE PER TITLE 22 REGULATIONS. · Stairs are NOT barricaded · The fireplace is properly screened with glass door · Verification of control of property on file · Property owner/landlord notification and consent on file · Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights forms are posted · Pediatric CPR and First Aid Card – expires on 2-29-2022 · Health & Safety Certificate – on file

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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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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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
	VISIT DATE: 11/17/2021

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· There are no bodies of water as of this date. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time.
· Current roster NOT on file
· Documentation of fire drills on file- last completed 6-4-2021
· Children’s records are NOT complete
· No employees
· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed.
Resident and/or staff records reviewed on 11-17-2021 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514- 0383 (TTY) and link to publication : Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
· For more information on SIDS and Safe Sleep Environments, please visit:
California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

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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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
	VISIT DATE: 11/17/2021

NARRATIVE

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AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Risk-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep

The following was reviewed with the licensee(s):
- SB 277 – Immunizations, Personal Beliefs Exemption, effective January 1, 2016 - it eliminates the exemption from existing specified immunization requirements based upon personal beliefs, and only allows an exemption from future immunization requirements deemed appropriate by the State Department of Public Health or a medical professional for medical reasons.
- AB290 – Child Nutrition, effective January 1, 2016 - – In accordance with California Health and Safety Code Section 1596.866 - each family day care home licensee who provides care, shall have at least one hour of childhood nutrition training as part of the preventive health practices course or courses.
- SB792 – Immunization requirements for staff, volunteers, effective September 1, 2016 – In accordance with California Health and Safety Code Section 1597.622(a)(1) - a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination or they may provide a statement declining the vaccination. If employees/volunteers are receiving the influenza vaccination, they must do so between August 1 and December 1 of each year.
- AB2231 (2016) – Increased Civil Penalties, effective July 1, 2017 – For failing to correct a violation the civil penalty is increased to $100 per day for EACH violation until corrected; For failing to correct a repeated violation the civil penalty is increased to $250 immediately assessed , and $100 per day afterwards for EACH repeated violation until corrected; For an Immediate Risk violation the civil penalty is increased to $500 immediately assess, and $100 per day for

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 3 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
	VISIT DATE: 11/17/2021

NARRATIVE

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EACH violation after that until corrected; For any repeated Immediate Risk violations the civil penalty is increased to $1,000 immediately assess, and $100 per day afterwards for EACH repeated violation until corrected.
NOTE: Repeat violations are defined as a violation of a previously cited statutory or regulatory Section and/or subsection within 12 months prior.
- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – In accordance with California Health and Safety Code Section 1596.8662 – requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. Existing licensees must meet requirements by March 30, 2018. New employees shall have 90 days to complete training as required. This training requirement may be directly met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/ and are provided in English and Spanish. If no training is made available in a required person’s primary language then those persons shall be exempt from this requirement
- AB2370 – Effective January 1, 2019 – Lead Poisoning – providers are required to provide a lead toxicity prevention handout to parents/guardians of newly enrolled and newly reenrolled children with information on risks and effects of lead poisoning; blood lead testing recommendations and requirements; and options for obtaining blood lead testing, including free and/or discounted testing. There will be a training component of this added to the Preventative Health Training beginning July 1, 2020.
- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

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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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
	VISIT DATE: 11/17/2021

NARRATIVE

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- Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited
- The applicant is urged visit the U.S. Consumer Product Safety Commission webpage at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled
- Once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
- Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov.
- Please subscribe at www.childcareadvocatesprogram@dss.ca.gov to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. This website can also be accessed through www.ccld.ca.gov
- The Duty Officer is available to answer questions Monday – Friday at 1-844-LET-US-NO (1-844-538-8766).

Once all corrections have been made, with proof sent to licensing, the application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. As agreed upon by the licensee, all corrections are due within 30 days. If not received within 30 days from the date of this report, the application may be withdrawn and the license will remain a Small Family Child Care Home.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 5 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
	VISIT DATE: 11/17/2021

NARRATIVE

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See LIC809D for cited deficiencies.
Appeal rights were provided and discussed.

During the exit interview, the Licensee, Yvonne George, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

As a REMINDER: When your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and TB Screen and have your child submit for LIVESCAN background clearance. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit the LIC508, TB screening and obtain a background clearance through LIVESCAN.

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC9099D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT).

A copy of this report was provided to the Licensee on this date and must be made available to the public upon request for the next 3 years.

Notice of site visit issued.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 6 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/19/2021 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
	8 9 10 11 12 13 14	Based on the interview/record review, the Licensee did not meet Operation of a Family Child Care Home regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review a current and complete roster. Licensee stated she does not have a current roster on file.	8 9 10 11 12 13 14
Type B 11/19/2021 Section Cited	1 2 3 4 5 6 7	INFANT SAFE SLEEP (j)The provider shall supervise infants while they are sleeping and adhere to the following... (2)The provider shall check and document the following: (D) Documentation shall be maintained in the infant’s file and be available to the Department for review... a. Date b. Infant's name. c. Time of each 15-minute check
	8 9 10 11 12 13 14	Based on the interview/record review, the Licensee did not meet Safe Sleep regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review a sleep log for C1 and C2. Licensee stated she does not have a sleep log for C1 and C2 available for review.	8 9 10 11 12 13 14

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 7 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/19/2021 Section Cited	1 2 3 4 5 6 7	Infant Safe Sleep An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.
Type B 11/19/2021 Section Cited	1 2 3 4 5 6 7	Child's Records (a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). Based on the interview/record review, the Licensee did not meet the Child’s Records regulation which poses a potential Health, Safety & Personal Rights risk to the children
	8 9 10 11 12 13 14	in care. During the record review the LPA was unable to review an LIC 700, LIC 9150, LIC 995 and LIC 627 for C1, C2, C3 an C4. During the review LPA reviewed some forms that were not child care forms. Licensee stated she does not have the forms and/or correct forms available for review.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 8 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2021 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (3) Where children less than five years old are in care, stairs shall be fenced or barricaded.
	8 9 10 11 12 13 14	Based on the observation, the Licensee did not meet the Operation of a Family Child Care Homes which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA observed stairs that were not barricaded. LPA also observed four children under the age of five. Licensee stated she does have two barricades	8 9 10 11 12 13 14
Type A 11/17/2021 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (4)...and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
	8 9 10 11 12 13 14	Based on the observation , the Licensee did not meet the Operation of a Family Child Care Homes which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA observed cleaning agents and several candles labeled “Keep out of Reach of Children” in the childrens bathroom.	8 9 10 11 12 13 14	Licensee agrees to remove all cleaning agents, candles and other hazardous items in the bathroom and send pictures to the Department by COB on 11-17-2021. Licensee also agrees to put away all hazards in the backyard and send pictures to the Department by COB on 11-17-2021.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

Page: 9 of 10

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: GEORGE FAMILY CHILD CARE	FACILITY NUMBER: 364807680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/19/2021 Section Cited	1 2 3 4 5 6 7	AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – In accordance with California Health and Safety Code Section 1596.8662 – requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew
	8 9 10 11 12 13 14	their training every two years.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

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