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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700045
Report Date: 09/12/2019
Date Signed: 09/12/2019 01:52:39 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:HANEY FAMILY CHILD CAREFACILITY NUMBER:
367700045
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
09/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Cassandra HaneyTIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPAs) Lady King and Aaron Mabika met with, Cassandra Haney today for the purpose of a Case Management inspection with regards to a self reported unusual incident. LPAs observed two children present during inspection. Licensee provided a copy of the Facility roster, list of children living in the home and Emergency contacts of current day care children. LPAs took pictures of the day care activity areas.

LPAs informed licensee that investigator, Hector Quantanar would contact her for additional information.

Based on the information provided, further investigation is needed.

Notice of Site Visit form was given and is to be posted for 30 days.

Exit interview was conducted with Licensee, Cassandra Haney and a copy of this report was read and given to Licensee, Cassandra Haney

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Aaron MabikaTELEPHONE: (661) 305-7599
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
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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