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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009629
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:50:21 PM

Document Has Been Signed on 08/18/2022 04:50 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
198009629
ADMINISTRATOR:RIVAS, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 496-2059
CITY:HAWAIIAN GARDENSSTATE: CAZIP CODE:
90716
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
08/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Guadalupe Rivas, LicenseeTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Plan of Correction (POC) inspection on this date. LPA met with Licensee, Guadalupe Rivas, who guided analyst on a tour of the facility. Also present at the facility was Licensee's minor daughter. LPA observed 5 children present including 2 infants.

Upon arrival, LPA observed Child 1, 11-month old infant, who was in an infant rocker inside a playpen in the living room, this poses an immediate risk to the health and safety of children in care. Licensee removed the child from the infant rocker and placed the rocker in the garage inaccessible to children in care.



The purpose of this inspection was determine if Licensee has corrected the deficiency cited on 7/27/22. LPA determined the following POC to be cleared:
  • The licensee is ensuring the personal rights of children in care are not violated.
  • LPA reviewed children's files and observed Immunization records
  • LPA observed Notice of Site visit & 809 report from 7/27/22 to be posted on the parent board by the front door visible to parents in care.

Per licensee, they did not understand to have parents sign the LIC 9224, LPA explained in Spanish that 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 form must be maintained in each child’s file immediately upon receipt from parent.
Based on observations,
Exit interview was conducted Guadalupe Rivas, Licensee, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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 08/18/2022 04:50 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 08/18/2022 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
102425(b)

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102425 (b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
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Licencee removed the infant for the infant rocker and placed the rocker in the garage. Per licensee, they will take an online class on Infant Safe Sleep and will provide proof to LPA by email by 8/25/22
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LPA observed Child #1, 11-month old infant, who was in an infant rocker inside a playpen, this poses an immediate risk to the health and safety of children in care
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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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


LIC809 (FAS) - (06/04)
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