<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845376
Report Date: 09/06/2022
Date Signed: 09/06/2022 06:52:41 PM


Document Has Been Signed on 09/06/2022 06:52 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:BURGOS FAMILY CHILD CAREFACILITY NUMBER:
364845376
ADMINISTRATOR:BURGOS, YOLANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 275-0342
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:14CENSUS: 13DATE:
09/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Yoland Burgos licenseeTIME COMPLETED:
06:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On the above noted date and time Licensing Program Analyst (LPA) arrived at the facility to conduct a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 08/24/22 and reported to the duty officer on 08/22/2022.

On this date facility records were reviewed, documents obtained, and written statements have been submitted. A tour of the facility was conducted, a census and children's play and nap area inspected. Further information will be needed.

Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

A notice of site visit was given and must remain posted for 30 days, failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, a copy of this report was provided to the licensee on this date and must be made available to the public upon request for the next 3 years.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-205-9491
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1