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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018549
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:22:03 AM

Document Has Been Signed on 12/06/2022 11:22 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HEREDIA FAMILY CHILD CAREFACILITY NUMBER:
198018549
ADMINISTRATOR:HEREDIA, CELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 305-0410
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Celina HerediaTIME COMPLETED:
11:30 AM
NARRATIVE
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Case management inspection conducted by Licensing Program Analyst Jennifer Hua. LPA met with licensee Celina Heredia. During the course of the case management visit, licensee confirmed that a report was not made to the Department as required regarding an incident that occurred on 11/23/2022, where an infant ingested a poisonous fruit.

Based on information received, deficiency is cited on attached 809D.

An exit interview conducted with licensee. Copy of report provided. Notice of Site Visit provided and shall be posted for 30 days in an area accessible for review or a civil penalty of $100 will be assessed.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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 12/06/2022 11:22 AM - It Cannot Be Edited


Created By: Jennifer Hua On 12/06/2022 at 10:32 AM
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HEREDIA FAMILY CHILD CARE
FACILITY NUMBER: 198018549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2022
Section Cited
CCR
102416.2(a)(b)(1)

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Reporting Requirements. The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). The licensee shall report any of the events as specified in Health & Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that
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Per licensee, will submit report LIC 624b to the Department by POC due date.
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occur during the operation of the family child care home. Medical treatment means treatment by a medical professional, as defined in Section 101152(m). The requirement is not met as evidenced by: Licensee did not report incident to the Department as required.
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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:Ana Chico
LICENSING EVALUATOR NAME:Jennifer Hua
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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