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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843616
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:52:05 PM


Document Has Been Signed on 03/21/2022 02:52 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:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
364843616
ADMINISTRATOR:DELORES RIVASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 328-8477
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:14CENSUS: 3DATE:
03/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Delores RivasTIME COMPLETED:
03:06 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 03/14/22. The incident occurred on 03/14/2022.

Description of the incident: Licensee Foster-guardian, Child #1, made accusation regarding Staff #2 discipline and Licensee taking Child #1 to Urgent Care.

Licensee took Child #1 to Urgent Care in which the doctor prescribed an ultra sound for a bump on his stomach. Child #1 was upset and told school (Hesperia High School) staff he was being disciplined. No day children are involved.

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: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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