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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020582
Report Date: 01/26/2023
Date Signed: 01/26/2023 06:11:23 PM

Document Has Been Signed on 01/26/2023 06:11 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:FLORES FAMILY CHILD CAREFACILITY NUMBER:
198020582
ADMINISTRATOR:JOHANA M. FLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 627-0074
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee, TIME COMPLETED:
06:30 PM
NARRATIVE
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At 3:00 pm Licensing Program Analyst (LPA) Roxana Lopez conducted an announced case management-incident inspection to the above facility on 1/26/2023. LPA met with Johana Flores, Licensee, who guided analyst on a tour of the facility. The purpose of this inspection is to follow up on an incident reported on 1/25/2023.

Based on the LPA’s observations and records review, the following deficiency listed on the attached LIC 809D (deficiency page) is being cited in accordance with California Code of Regulations Title 22. Deficiency that is being cited needs to be cleared to protect the children’s health & safety.

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 conducted and report was reviewed with Licensee, Johana Flores.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/26/2023 06:11 PM - It Cannot Be Edited


Created By: Roxana Lopez On 01/26/2023 at 05:29 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2023
Section Cited
CCR
102416(c)(1)

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102416(c)(1) Personnel Requirements-The licensee... shall complete training on... pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.(1) A current pediatric cardiopulmonary resuscitation card issued either by the
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which poses/posed a potential health, safety or personal rights risk to persons in care
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American Red Cross or the American Heart Association, or by a training program that has been approved by the Emergency Medical Services...Based on record review, the licensee did not comply with the section cited above in that their CPR is not EMSA approved
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Per Licensee, she will take a EMSA approved pediatric cpr course and submited to LPA by POC due date.

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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Roxana Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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