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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006954
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:06:43 PM

Document Has Been Signed on 02/28/2024 03:06 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:BUSTAMANTE FAMILY CHILD CAREFACILITY NUMBER:
192006954
ADMINISTRATOR:BUSTAMANTE, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 448-8406
CITY:SOUTH EL MONTESTATE: CAZIP CODE:
91733
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 5DATE:
02/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Martha Bustamante, Licensee TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced case management- incident inspection to the above facility. The purpose of this inspection was to follow-up on an incident that was self- reported to the department on 1/24/2024. LPA met with Licensee Martha Bustatmante, who guided analyst on a tour of the facility. Census was taken

On 1/24/2024 an incident was self reported to the department- report was reported within the required 24 hours and written report was received within 7 days.

LPA interviewed license to gather additional information and obtained documents pertaining to incident- no disclosures were made on this date.

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Licensee, Martha Bustamante.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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