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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627917
Report Date: 03/10/2022
Date Signed: 03/10/2022 01:33:28 PM


Document Has Been Signed on 03/10/2022 01:33 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:PAGAN, NINA FAMILY CHILD CAREFACILITY NUMBER:
376627917
ADMINISTRATOR:NINA PAGANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 940-8993
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:14CENSUS: 12DATE:
03/10/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nina PaganTIME COMPLETED:
01:40 PM
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On at March 10, 2022 at 12:45 p.m. Licensing Program Analyst (LPA) Leilani Curtis conducted an unannounced case management inspection. Upon arrival LPA met with Licensee Nina Pagan and toured the facility. There were 12 children present, one was under 24 months. Also present was the licensee’s helpers Ann Naibova and Garegin Naibov. The facility was observed operating within ratio and capacity The purpose of today’s inspection is to verify that the deficiencies related to the licensee’s disaster/fire drill log and children’s emergency information cards cited on LPA Leilani Curtis’s annual inspection dated 11/15/21 have been addressed. On 11/22/21 and 11/30/21 the licensee sent LPA identification and emergency information forms, LIC700, for two children. The LIC700 for two other children, C1 and C2 were not submitted. During today’s inspection LPA Curtis verified that the last documented disaster/fire drill occurred on 1/27/22. The licensee states that the two children missing the identification and emergency information forms, LIC700, no longer attend the facility.

No deficiencies are cited.

LPA reviewed this report with Licensee. The licensee was provided a copy of her appeal rights (LIC 9058 01/16) and her signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Licensee post notice of site visit.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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