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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019571
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:50:15 PM

Document Has Been Signed on 10/26/2021 03:50 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:VALENZUELA FAMILY CHILD CAREFACILITY NUMBER:
198019571
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
10/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dolores Valenzuela TIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management inspection. This inspection is for the purpose of clearing deficiencies from a previous October 13, 2021 inspection. Upon arrival LPA met with Licensee Dolores Valenzuela who was providing care for six children (LPA verified from child records: four preschool and two infants). LPA observed all areas of home to confirm census.

LPA observed the following numbered items to be cleared:

1. The total licensed capacity for a Small Family Child Care Home shall not exceed eight children. LPA observed the facility to be in compliance. and therefore the citation has been cleared. Licensee was also within ratio.

2. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. LPA observed a July 19, 2021 receipt for fire extinguisher which indicates the extinguisher is in compliance. The fire extinguisher should be serviced or a new one can be purchased by July 19, 2021.

Open items: The Licensee is scheduled to renew CPR on October 31st, 2021 and will submit evidence later.

Note: LPA reminded Licensee of possible capacity and ratio scenarios approved under Title 22. LPA also reminded Licensee of the following:

Exit interview was conducted with Licensee Valenzuela. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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