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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493072
Report Date: 04/11/2024
Date Signed: 04/15/2024 02:56:35 PM


Document Has Been Signed on 04/15/2024 02:56 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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:PACLEB FAMILY CHILD CAREFACILITY NUMBER:
197493072
ADMINISTRATOR:PACLEB, BYANKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 500-2960
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY:14CENSUS: 13DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Byanka PaclebTIME COMPLETED:
12:20 PM
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On 04/11/24 Licensing Program Analyst (LPA) Ranita Richmond conducted a case management at the above mentioned facility.

This casemanagement is to verify Ernest Davis Jr. works at the facility as the music teacher. LPA Richmond verified that Mr. Davis comes to the facility once weekly to provide music and movement with the children in care.

During visit Mr. Davis was not left alone with children in care. Technical violation is issued. Licensee will request for Mr. Davis to be fingerprint cleared.

Licensee will provide trustline forms to Mr. Davis on 4/12/24.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Ranita RichmondTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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