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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700045
Report Date: 09/12/2019
Date Signed: 09/12/2019 01:56:06 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: 2DATE:
09/12/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cassandra HaneyTIME COMPLETED:
02:30 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
Licensing Program Analysts (LPAs) Lady King and Aaron Mabika met with, Cassandra Haney today for the purpose of a Case Management inspection with regards of a self reported unusual incident. Licensee reported the incident to CCL on the 10th of September 2019. Licensee became aware of the incident on the 29th of July 2019.

Based on the information obtained the unusual incident was not received in a timely manner.

A type B deficiency has been cited per Title 22 regulations for reporting requirements. See LIC809D for details.

Appeals rights were given to licensee. Report was signed and a copy was given to licensee per Title 22 regulations. Notice of Site Visit was given to licensee and is to be posted for 30 days

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)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 367700045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2019
Section Cited

1
2
3
4
5
6
7
102416.2 Reporting Requirements
(a) The licensee shall report the following information to the Department by telephone or fax within the next business day and during normal working hours (8am to 5pm).This requirement
8
9
10
11
12
13
14
was not met as evidenced by; LPAs received information that Licensee was informed of the Unusual Incident Report on the 29th of August and reported it to CCL on 10 th of September 2019.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2