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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192005642
Report Date: 05/21/2025
Date Signed: 05/21/2025 02:33:01 PM

Document Has Been Signed on 05/21/2025 02:33 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
192005642
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 388-4877
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
05/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee, Maria Lopez TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Monica Ruiz conducted an unannounced case management inspection to follow up on an incident that was reported to the Department on 5/14/2025 via email. Upon arrival, LPA announced purpose of inspection and met with Licensee, Maria Lopez, who provided LPA a tour of the facility inside and outside. Census was taken.
On 5/14/25, an incident was reported to the department where a child lost consciousness after falling. The facility reported this incident to the Department within the required 24 hours. During this inspection LPA interviewed staff who observed incident.
Licensee states that she did not witness incident. Licensee states her assistant (S1), see LIC 811-confidential names, was watching Child #1 (C1) play in the infant area when incident occurred. Licensee states she was in the kitchen preparing breakfast when she heard S1 yell for her to call 911 because C1 wasn't breathing.
Licensee states there were 4 children present at the time of the incident. The three older children were in the main day care area enjoying free choice time.
S1 states that on 5/14/25 at approximately 8:15am, child was kneeling down while pulling toys out of a little basket in the infant area, when she fell backward onto the matted floor. S1 states she was sitting with C1 on mat and saw C1 fall back but could not reach her in time. S1 states she saw C1 fall onto their back and then saw the whites of C1's eyes. assistant states C1 was unresponsive and appeared lifeless. Assistant yelled for Licensee to call 911. Licensee was in the kitchen when she heard S1 yell for her to call 911 because C1 wasn't breathing. Licensee called 911 and was placed on hold.

NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Monica Ruiz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 192005642
VISIT DATE: 05/21/2025
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S1 states C1 regained consciousness and began to breath normally while Licensee was on still on hold. S1 states, Licensee hung up and called C1's mother to pick up child. Licensee informed mother of incident and told her child stopped breathing. Licensee advised mother to take C1 to doctor.
C1's mother informed Licensee that she took C1 to the doctor and doctor did not find anything wrong. Mother provided note to Licensee, clearing C1 to return to child care.
C1 has attended day care since the reported incident. C1 was not present today due to illness. LPA inspected infant care/nap area for hazards and did no observe any sharp edges, loose parts or hazards in the infant care area.
LPA observed the floor of infant/nap area to be carpeted with a large area rug and on top of that there is a soft baby mat. LPA observed 3 (three) wicker baskets containing stuffed animals and sensory toys, an activity mirror mounted to the wall, and a book shelf in the infant care area.

LPA interviewed Child #2 who was in the play area and witnessed child fall. See LIC 812.

Based on the information obtained and LPA observation of the play area, LPA determined there was adequate supervision provided the day of the incident.
NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Monica Ruiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC809 (FAS) - (06/04)
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