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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700046
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:52:39 PM


Document Has Been Signed on 11/09/2022 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:JENSEN FAMILY CHILD CAREFACILITY NUMBER:
367700046
ADMINISTRATOR:JENSEN, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 963-6114
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY:14CENSUS: 7DATE:
11/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:JENSEN MARIATIME COMPLETED:
03:02 PM
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On 11/09/2022, at 1:48 PM Licensing Program Analyst (LPA) Babatunde Ibitoye met with Director Jensen Maria to conduct an Unannounced case management inspection to follow-up on a self- reported unusual incident report submitted by the facility on 11-02-2022. Upon arrival, LPA observed 7 children and 2 staff members.

Description of incident: on 11/01/22 Child #1 mom called and said C#1 told her C#2 grabbed his Private part.Per reporting party two staffs were outside with 5 children and didn't see anything. See Lic 811

Based on the information gathered from observations and interviews conducted with the staffs additional follow up is needed.

Exit interview was conducted, report was read, and a copy of this report was given to facility director along with the appeal rights and notice of site visit.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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