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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021094
Report Date: 03/08/2023
Date Signed: 03/08/2023 01:30:36 PM

Document Has Been Signed on 03/08/2023 01:30 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:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
198021094
ADMINISTRATOR:MARTINEZ, YENYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 335-9292
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 1DATE:
03/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Yeny Martinez, LicenseeTIME COMPLETED:
01:45 PM
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On March 8, 2023, Licensing Program Analysts (LPAS) Monique Ayala and Mary Silva conducted an unannounced case management inspection. A COVID-19 risk assessment was conducted prior to entering the facility. LPAs met with licensee who guided LPAs on a tour of the facility. Also present in the home was licensee's assistant Lucia Martinez. LPAs observed 1 child in care.

The purpose of the inspection is to conduct a health and welfare check to ensure the health and safety of the children in care is met. LPA's reviewed children files and observed that child #1 (C1) did not have a file with all required licensing forms.

During this inspection LPA's reviewed the facility roster.

Licensee is being cited three Type B deficiencies in accordance with Title 22 Regulations,102421(a),(b) and (c).

An exit interview was conducted and a copy of this report was provided to licensee, Yeny Martinez along with Notice of Site Visit and Appeal Rights.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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Document Has Been Signed on 03/08/2023 01:30 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/08/2023 at 12:59 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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
102421(a)

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Child's Records: The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
This requirement was not met as evidence by: based on record review and interviews with licensee, C1 does not have a file at the facility. This poses a potential health and
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Licenesee states before enrollment all required forms will be in the childrens file prior to providing care.
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safety risk to children in care.
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Type B
03/17/2023
Section Cited
CCR102421(b)

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Child's Records: The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).This requirement was not met as evidence by: based on record review and interviews with licensee,
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Licenesee states before enrollment all required forms will be in the childrens file prior to providing care.
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 C1 does not have a file at the facility. This poses a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/08/2023 01:30 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/08/2023 at 01:08 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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
102421(c)

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Child's Records: In any case in which the licensee cares for an additional child pursuant to Section ... 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child's record, a copy of documentation verifying the child's enrollment and attendance at kindergartne, including
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Licenesee states before enrollment all required forms will be in the childrens file prior to providing care.
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 transitional kindergarten...This requirement was not met as evidence by: based on record review and interviews with licensee, C1 does not have a file at the facility. This poses a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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