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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843616
Report Date: 10/02/2019
Date Signed: 10/02/2019 12:16:13 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: 5DATE:
10/02/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Delores RivasTIME COMPLETED:
12:31 PM
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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 informed parent and CCL.

Based on information provided and interview with Staff #1 the incident needs further investigation. 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: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
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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