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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842969
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:25:38 AM


Document Has Been Signed on 05/17/2022 11:25 AM - 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:MALDONADO FAMILY CHILD CAREFACILITY NUMBER:
364842969
ADMINISTRATOR:MALDONADO, KASEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 338-9836
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:14CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kasey Maldonado LicenseeTIME COMPLETED:
11:32 AM
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Licensing Program Analyst (LPA) Steven Montoya met with Licensee Kasey Maldonado to follow up on Unusual Incident reports dated: 5-16-2022. Licensee reports a child being injured (ankle) at FCCH. At the time of the visit, there were 4 children in care (which includes the injured child).

LPA inspected the home for heath and safety according to title 22 regulations. LPA interviewed one child and observed video of child being injured on the security monitoring system. Licensee reports parent was immediately notified and came and took child to the hospital. Licensee provided the LPA with a copy of the Child Care roster and reviewed video coverage of the incident. No medical report was given to licensee.

Licensee was given a copy of appeals rights, copy of report and notice of site visit.

Exit.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 202-4701
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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