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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843616
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:05:23 PM

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:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
364843616
ADMINISTRATOR:DELORES RIVASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 328-8477
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:14CENSUS: DATE:
12/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Delores RivasTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPA) Thompson-Miller met with Delores Rivas, Licensee, for a Case Management Incident inspection involving an Incident Report dated 11/22/2021. The incident occurred on 11/22/2021.

Description of the incident: Licensee (Foster-guardian) preventing guardianship (Foster child) child access to medication and medical supplies
Licensee is a foster/guardian parent of child who takes insulin (as needed, three times a day). Licensee stated no day care children were present during the incident .

Based on the interview conducted the incident does not appear to have been the result of any violation of the Title 22 regulation, therefore, no deficiencies were cited.

An exit interview was conducted, a copy of this report was read and provided to Delores Rivas, Licensee, on this date.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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