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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020582
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:46:35 AM

Document Has Been Signed on 09/29/2023 10:46 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: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: 0CENSUS: 1DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee,Johana Flores TIME COMPLETED:
11:00 AM
NARRATIVE
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At 9:20 am Licensing Program Analyst (LPA) Roxana Lopez conducted an announced case management other inspection to the above facility. A Covid risk assessment was conducted upon entry. LPA met with Johana Flores, Licensee, who guided analyst on a tour of the facility. The purpose of this inspection is to confirm operating status and to follow up on incident self-reported on 1/25/2023. Present during inspection was Licensee and licensee's son.
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Per Licensee, they are currently, not providing care and unsure of when they will be reopening. LPA Lopez offered Licensee to go on inactive status and provided form LIC 9211. Per Licensee, they will consult with their attorney first and keep LPA updated.

This incident was also conducted by CCLD Investigations Branch (IB), Investigator Lorraine Patterson. Investigator Patterson obtained documents related to the incident.

Licensee, informed LPA Lopez that they will like to schedule a meeting with LPA and LPM (Licensing Program Manager). LPA advised that they will speak to manager and keep Licensee informed.

Based on the investigation’s findings, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 198020582
VISIT DATE: 09/29/2023
NARRATIVE
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LPA Roxana Lopez informed licensee (Johana Flores) that this report dated 9/29/2023 document(s) (1 Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Roxana Lopez informed the licensee to provide a copy of this licensing report dated 9/29/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 10:46 AM - It Cannot Be Edited


Created By: Roxana Lopez On 09/29/2023 at 09:53 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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
102402(a)(3)

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Revocation or Suspension of a License or Registration : (a) The Department shall have the authority to suspend or revoke any license for the following reasons: (3) Conduct in the operation or maintenance of a family day care home which is inimical to the health, morals, welfare, or
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Licensee will submit a written plan on what actions will be taken to inform parents when children are sick. Decleration will be emailed to LPA by 10/6/2023
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safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above due to delay of contacting parents to inform them
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that child was showing signs of distress. The child was restless, showed signs of labored breathing, was wheezing, coughing, and not swallowing which poses/posed an immediate health, safety, or personal rights risk to persons in care. The child was dropped off at 06:00 am and emergency medical (911) was contacted at 09:30 am.

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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: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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