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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843616
Report Date: 10/21/2019
Date Signed: 10/21/2019 02:00:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
364843616
ADMINISTRATOR:DELORES RIVASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 328-8477
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:14CENSUS: 8DATE:
10/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Delores RivasTIME COMPLETED:
02:16 PM
NARRATIVE
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Licensing Program Analyst (LPA) Thompson-Miller met with Delores Rivas, Licensee, for a Case Management Incident inspection involving an Incident Report dated 09/28/19. The incident occurred on September 27, 2019.

Description of the incident: Child #1 was at the local park rolling around (playing) and hurt her right wrist.
Staff #1 took children to the local park to play. Children were rolling on the grassy area. Child #1 informed Staff #1 her right wrist hurt, no bruising, swelling or blood was observed. Licensee followed proper protocol and informed parent and CCL.

Based on information provided and interviews conducted the incident does not appear to have been the result of any violation of the Title 22 regulation. However, LIC809D citation is being issued for over capacity while at the park.

Exit interview conducted and a copy of report provided to Licensee, Delores, Rivas on this date.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 364843616
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2019
Section Cited

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Staffing Ratio and Capacity: (e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
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This requirement was not met as evidenced by: Licensee admission of having 9 children while at the park.
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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: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2019
LIC809 (FAS) - (06/04)
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