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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004738
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:27:50 PM

Document Has Been Signed on 04/27/2023 12:27 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PUEBLO CHILD DEVELOPMENT CENTERFACILITY NUMBER:
198004738
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:1444 E. HOLT AVE., ROOM 3TELEPHONE:
(909) 994-3796
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 1DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kym Allen TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Judy Mora conducted a case management inspection due to an incident that occurred on 03/08/2023. LPA met with Kym Allen, Child Development Facilities Licensing Planner, who guided LPA on a tour of the facility at approximately 11:20 AM. LPA obtained documentation during this visit.

The incident that occurred on Wednesday, March 8, 2023 was reported to the Department via telephone and email within the required 24 hours.

Staff #1 who was involved in the incident was not present at the facility during this inspection. The child, C1, was also not present.

Based on the information provided during this visit, further investigation is needed regarding the incident. A follow up inspection will be conducted at a later date.

At this time, there are no deficiencies being cited.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted with Kym Allen.

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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