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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009277
Report Date: 11/19/2019
Date Signed: 11/19/2019 03:19:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:BERNAL LOPEZ, LILIANA FCCHFACILITY NUMBER:
493009277
ADMINISTRATOR:BERNAL LOPEZ, LILIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 364-4546
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:14CENSUS: 10DATE:
11/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Liliana Bernal LopezTIME COMPLETED:
03:30 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
A case management visit was made to the facility by Licensing Program Analyst (LPA) Jennifer Velasco in response to an Unusual Incident Report (UIR) filed by licensee (L1).

During today's case management visit, LPA met with L1, who along with an assistant (S1) was providing care to ten children under ten years of age. LPA toured the facility, reviewed facility documents, and discussed the 11/13/2019 incident in which a child (C1), who was 1.5 years old, sustained injury. L1 and an assistant had taken the children for a walk, and C1 fell, hitting a cement pillar and sustaining a bump on his face. L1 stated she returned home, notified the parent, and provided first aid. L1 stated initially C1 seemed to be fine but that later in the day, C1 appeared to feel unwell. L1 contacted C1's parent (A1), who took C1 for medical assessment and treatment. L1 notified CCLD by telephone on 11/14/2019, by mail (received on 11/18/2019), and contacted LPA by telephone on 11/14/2019.

No deficiencies were cited as a result of this case management visit.

Notice of Site Visit to be posted for 30 days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
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 1