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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495103
Report Date: 06/10/2022
Date Signed: 09/27/2022 08:58:01 AM


Document Has Been Signed on 09/27/2022 08:58 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/27/2022 09:03 AM

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

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On 6/10/2022, LPA Lillian Casillas, Regional Manager Victor Bautista, and Licensing Program Manager Maureen Neal conducted a virtual office visit as part of a non-compliance conference with Licensee, Irma Castillo.

During today's conference call, Licensee acknowledged she signed and submitted a LIC 855 Declaration on 5/18/2022, stating the landlord signed the LIC 9149 Landlord Consent form, which is a false statement. A Type A violation is being cited for conduct inimical based on the LIC 855 Declaration (See LIC 809-D).

Upon receipt of this report, the Licensee shall post the Notice of Site Visit (LIC 9213) and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224) form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224).

An exit interview was conducted. A copy of this report was provided to Licensee, Irma Castillo, along with Appeal Rights via email. Licensee emailed the signed report to LPA Casillas via email on 6/13/2022. Esta junta fue llevada acabo en Espanol.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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Document Has Been Signed on 06/15/2022 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CASTILLO FAMILY CHILD CARE
FACILITY NUMBER: 197495103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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102402 Revocation or Suspension of a License or Registration (a) The Department shall have the authority to...revoke any license for the following reasons: (3) Conduct...inimical to the health, morals, welfare, or safety...
This requirement was not met as evidenced by:
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Licensee agrees to enroll in an ethics course within 45 days. Licensee must submit the course curriculum prior to enrollment for the Department's approval. Upon completion, Licensee agrees to submit a summary of the material learned as well as a certificate of completion to the Department.
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Licensee admitted to signing and submitting a LIC 855 Declaration with false statements related to the LIC 9149 Landlord Consent form, which poses an immediate health, safety or personal rights risk to children in care.
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Licensee agrees to increased monitored visits by Community Care Licensing.

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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: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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