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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403941
Report Date: 12/01/2022
Date Signed: 12/01/2022 08:54:48 AM

Document Has Been Signed on 12/01/2022 08:54 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:POLAND FAMILY DAY CAREFACILITY NUMBER:
197403941
ADMINISTRATOR:POLAND, VICTORIA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 841-8467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 2DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Victoria Poland, LicenseeTIME COMPLETED:
09:00 AM
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On 12/1/2022 at 8:20am, Licensing Program Analyst Adrian Risher conducted a case management visit for increased monitoring. LPA met with Victoria Poland and explained the purpose of the visit. LPA observed 2 children in care.

The purpose of the visit is to ensure the Licensee maintains a safe and comfortable environment for the children in care. LPA observed Licensee providing proper supervision over the children in care.

Licensee is enrolled with the Technical Support Program for technical assistance. LPA received copies of the Licensee's orientation and preventative health & safety certifications. Licensee provided declarations regarding Personal Rights as well.

Based on observations made by the LPA, no deficiencies will be cited today. LPA did not observe any violations during today's visit. Facility will continue to be under increased monitoring on a quarterly basis.

Exit interview was completed with Victoria Poland, Licensee. Appeal Rights will be provide
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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