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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376625408
Report Date: 10/26/2022
Date Signed: 12/12/2022 08:03:04 AM


Document Has Been Signed on 12/12/2022 08:03 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108



FACILITY NAME:RINCON, ADELAIDA FAMILY CHILD CAREFACILITY NUMBER:
376625408
ADMINISTRATOR:ADELAIDA RINCONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 475-6506
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:14CENSUS: 7DATE:
10/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Adela RinconTIME COMPLETED:
05:30 PM
NARRATIVE
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On 10/26/22 at 4:15pm, LPAs Adrian Castellon and Julissa Valle conducted an unannounced 10 day complaint inspection. LPAs met with licensee Adela Rincon.

During the complaint inspection, a licensing violation was noticed. Six children's records (LIC700) were not available upon request. This LIC809 and LIC809D will be used to document the citation.

See LIC809D for Type B deficiency cited.

Exit interview conducted. Appeal rights were discussed and given to assistant director on this date. Notice of Site Visit was given to licensee Rincon.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Adrian CastellonTELEPHONE: (619) 767-2237
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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 2


Document Has Been Signed on 12/12/2022 08:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: RINCON, ADELAIDA FAMILY CHILD CARE
FACILITY NUMBER: 376625408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited

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102421(b) Child's Records: (b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement was not met as evidenced by: licensee was not able to produce six children's records upon request. This could pose a threat to the health and safety to children in care.
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Licensee will submit proof (email) of singed completed children's records by 10/28/22. The email shall include all required forms.

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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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Adrian CastellonTELEPHONE: (619) 767-2237
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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