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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700045
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:49:36 PM


Document Has Been Signed on 04/26/2022 02:49 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:HANEY FAMILY CHILD CAREFACILITY NUMBER:
367700045
ADMINISTRATOR:HANEY, CASSANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 910-3573
CITY:TWENTYNINE PALMSSTATE: CAZIP CODE:
92277
CAPACITY:14CENSUS: 9DATE:
04/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Cassandra Haney TIME COMPLETED:
12:00 PM
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On April 26, 2022 at 10:30am License Program Analyst (LPA) Kendal Zirbes conducted an unannounced case management inspection to the family child care home. The purpose of the unannounced inspection was to follow up on the April 11, 2022 self reported unusual incident report. LPA announced the reason for the unannounced inspection and the Licensee granted LPA access to the home. At the time of the inspection, licensee was alone and providing supervision to a total of nine children.

During this inspection, LPA obtained a copy of the facility roster and conducted a safety inspection on the entire home which included the off -limits areas at 10:50am. Per LPAs conversation with the Licensee, the following people reside in the home, Licensee, child 1, child 2 and child 3.

Based on the information obtained, further investigation is required. A copy of the report, appeal rights and notice of site visit was provided to the licensee.


SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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