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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700503
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:35:28 AM

Document Has Been Signed on 10/26/2022 11:35 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BARNES FAMILY CHILD CAREFACILITY NUMBER:
197700503
ADMINISTRATOR:TERRY BARNESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 333-2897
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
10/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Terry Barnes, LicenseeTIME COMPLETED:
11:40 AM
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On 10/26/22, Licensing Program Analysts (LPAs) Justeene Tamayo and Andrea Pittman conducted an unannounced case management inspection to follow up on an Unusual Incident that happened on 10/16/22. Child #1 was aggressive with licensee and child #1 hit licensee while in care.

LPAs toured the facility and observed 2 preschool children and 1 infant in care. LPAs reviewed children's files and obtained other supportive documentation related to the unusual incident. LPAs interviewed child #2 and child #3, as well as the licensee.

At this time, no citations will be issued.

An exit interview was conducted and a copy of this report was provided to the licensee, along with her appeal rights and Notice of Site Visit.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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