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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021819
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:37:17 AM

Document Has Been Signed on 09/04/2025 11:37 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CHAVEZ FAMILY CHILD CAREFACILITY NUMBER:
198021819
ADMINISTRATOR/
DIRECTOR:		CHAVEZ ADRIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 717-0781
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
09/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Adriana ChavezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On Wednesday September 4 2025, Licensing Program Analysts (LPA) Kamile Martin conducted an announced Pre-Licensing inspection on this date for the purpose of inspecting the facility to ensure the health and safety standards as required by the regulations governing childcare homes are met for initial licensor. A copy of the Pre-licensing Entrance Checklist for Child Care homes form (LIC 9280) was provided.

LPA met with Adrian a Chavez applicant who confirmed the family members residing in the home, that consists of 3 adults and 2 minor. Present during this inspection was the Applicant adriana and her adult daughter. Applicant is requesting a large (14 Capacity) family child-care home license. Per Applicant, operating hours will be Monday to Friday, 6:00AM to 6:00PM. Applicant states that they will care for children 0 months - 12 years of age.

Applicant guided the LPA on a tour of the facility. All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a one-story home and consists of 3 bedrooms, 3 bathrooms, kitchen, living room, dining room, garage, front yard and back yard. The applicant understands that licensing staff may have access to off-limit areas during inspection visits, if necessary.

Per applicant, the children will have access to the bathroom in the bedroom area for toddlers and bed room for infants and back yard. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service, ventilation, and heating. Off-limits areas are the bedroom 1, Bedroom 2 and Bedroom 3 , the restroom inside bedroom 3, the dining room and the kitchen and which will be kept locked during operating hours and the kitchen which was observed to have a gate in place making it inaccessible to the children in care.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021819
VISIT DATE: 09/04/2025
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The bedrooms on limits will be the main day care area. The applicant stated that toddlers will nap in their room and infants will nap in their bedroom. And children wll eat outdoors. LPA observed mats as napping equipment. LPA observed age-appropriate toys, manipulatives, books and other materials available. The applicant states that the facility will provide breakfast, lunch, and snack Applicant was reminded to label and store all outside food properly ,Applicant states she will have the meal program.

LPA observed the smoke detector and carbon monoxide alarms which were tested and verified to be in operable condition. LPA also observed the required fire extinguisher (2A 10BC) located in the kitchen with the receipt verifying purchase on 5/14/25.

Per applicant there are no weapons or firearms currently in the facility and LPA did not observe any on this visit. LPA did not observe a swimming pool, or other bodies of water in or around the facility.

LPA observed a parent board with the required postings: Parents Rights PUB394, Emergency disaster plan LIC610A, Earthquake Preparedness Checklist LIC9148,

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safesleep, as an additional resource. LPA also informed [applicant, licensee, or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. .

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021819
VISIT DATE: 09/04/2025
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The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR, of which expires 05/27. Applicant completed mandated reporter training and expires 6/23/27. LPA also observed first aid supplies available on the premises

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

At time of inspection the following was discussed with the applicant:

• Criminal Record Clearance-Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-day.

or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

• Inspection Authority: All adults living and working in the home shall be made aware of the Department’s right to inspect the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults, review documentation and observe off limit areas if needed.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021819
VISIT DATE: 09/04/2025
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 The facility license number must be in all advertisements, publications or announcements with the intent to attract clients.

• Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

• Liability Insurance was discussed; LPA’s advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

• Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis (Tdap), & measles (MMR). The licensee & all adults working with children must have proof of immunization.

• Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees are to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

• LPA’s advised the applicant how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

• In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.

• Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.

• The fire extinguisher type 2A-10BC must be serviced or purchased annually by State Fire Marshall standards. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021819
VISIT DATE: 09/04/2025
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 Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

• Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

• Fire and safety drills must be performed every 6 month and documented for review by the Department.

• Smoking is prohibited in family childcare homes.

• Children and Staff records must be maintained and updated as needed and must be available for review by the Department. If Children and Staff leave the day care all records must be maintained for 3 years after leaving. Children’s roster LIC9040 must be maintained, kept running and available for review upon request.

• No infant walkers, no Johnny jumpers, no saucer chairs, no trampolines and any other item that falls into those categories, are not permitted in the facility.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication. Applicant’s email address was verified/obtained during this inspection. The applicant was advised that the email may be public information. (juniormacias12@yahoo.com)

MyChildCarePlan.org – Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On, 08/30/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 198021819
VISIT DATE: 09/04/2025
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Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under penalty of perjury that the statements on the application and any attachments are correct.

Based on licensing staff observations, the application will be submitted for final review to the department. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.

Exit interview was conducted and report was reviewed with the applicant Adrian Chavez

A notice of site visit was provided. Appeal rights were provided and discussed.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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