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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842907
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:00:10 PM

Document Has Been Signed on 10/04/2023 12:00 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
364842907
ADMINISTRATOR:PEREZ, PETRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 285-7175
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Petra Perez, Licensee TIME COMPLETED:
12:00 PM
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On 10/04/23, Licensing Program Analyst (LPA) Justeene Tamayo met with licensee Petra Perez, who guided LPA on a tour of the facility. The purpose of this visit was to conduct a follow up Case Management - Incident inspection for an Unusual Incident that was received by the Department on 09/08/23. The Unusual Incident was self reported within the time frame specified by regulations. Upon arrival, LPA observed 6 preschool children, with 2 staff present, and the licensee.

Description of incident: On 09/07/23, child #1 bit child #2 on more than one occasion.

After interviews conducted with staff, it was revealed staff #1 and licensee observed the incidents occur on 09/06/23 and 09/07/23 and it was accidental. Child #2 did not need medical attention, and the licensee took appropriate measures to ensure the health and safety of each child. Per licensee, she is now separating child #1 and child #2 to prevent the incidents from re-occurring. There was no immediate danger to child #1 and child #2 at this time.

No deficiencies are being cited at this time.

An exit interview was conducted, and a copy of this report was provided to the licensee, along with her Notice of Site Visit.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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