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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492985
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:08:06 PM

Document Has Been Signed on 09/28/2022 12:08 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
197492985
ADMINISTRATOR:HERNANDEZ, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 793-6987
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
09/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dolores HernandezTIME COMPLETED:
12:15 PM
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On 9/28/2022 Licensing Program Analyst (LPA) Carol Heath met with Dolores Hernandez for the purpose to conduct a Case Management visit. Upon arrival LPA’s observed 2 children in care.

The purpose of the visit is to conduct a health and welfare check to ensure the home meets State Licensing Title 22 Regulations: Backyard (Bodies of Water): See Section 102417(g) (5) (A).
102417 (g):
(5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

(A) Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.
A tour of the facility was conducted.
An exit interview was conducted, and a copy of this report was read and provided to Licensee Dolores Hernandez along with Notice of Site Visit.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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