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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006411
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:19:11 PM

Document Has Been Signed on 07/18/2023 03:19 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 S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MAYWOOD CHILD DEVELOPMENT CENTERFACILITY NUMBER:
192006411
ADMINISTRATOR:JOSEFINA PEREZFACILITY TYPE:
850
ADDRESS:4801 58TH STREETTELEPHONE:
(760) 942-3433
CITY:MAYWOODSTATE: CAZIP CODE:
90270
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Josefina PerezTIME COMPLETED:
03:50 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analyst (LPA), T. Tran observed the following deficiency:

During record reviewed and interview conducted with site supervisor, Josefina Perez, the facility failed to report the incident occurred on 5/17/23.

During today's visit, LPA obtained the LIC624 regarding the incident occurred on 5/1723 and the declaration statement of understanding the reporting requirements completed by site supervisor for the record.

Facility was cited a type B deficiency and plan of correction was cleared during the visit. See Facility Evaluation Report LIC 809D for deficiency cited.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the facility representative, Josefina Perez.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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Document Has Been Signed on 07/18/2023 03:19 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 07/18/2023 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MAYWOOD CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 192006411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2023
Section Cited
CCR
101212(d)(1)(2)

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Reporting Requirements
This requirement is not met as evidenced by based on record review facility failed to report an incident occurred on 5/17/23 which poses a potential health and safety risk to children in care.
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During today's visit, LPA obtained LIC 624 regarding this incident and declaration statement of understanding pertains to reporting requirement from site supervisor.
Plan of correction cleared during today's visit.
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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:Valarie Cook
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
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