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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300905
Report Date: 10/27/2021
Date Signed: 10/27/2021 06:06:50 PM

Document Has Been Signed on 10/27/2021 06:06 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:JACOBO-SEGUIN, CORINNEFACILITY NUMBER:
304300905
ADMINISTRATOR:JACOBO-SEGUIN, CORINNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 638-7510
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Assistant Angelica RiosTIME COMPLETED:
01:20 PM
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On 10/27/2020 at 11:40 AM, Licensing Program Analyst (LPA) Tina Nguyen conducted a case management investigation for the incident that the facility self-reported to licensing office on 10/26/2021 regarding personal rights. After conducting Facility Risk Assessment, the case management needs to conduct via Tele-Inspection.

LPA Nguyen met with assistant Angelica Rios via facetime. LPA Nguyen also talked to licensee Corinne Jacibo-Seguin via telephone. During today's investigation, census was taken. There was a total of 6 preschool age children; 1 school age child and 2 staff members observed.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today’s inspection, the facility roster and additional documents were requested. The licensee indicated that she will email the documents to LPA Nguyen via email. Due to insufficient information available and further interviews needed with child is not present, the aforementioned allegation needs further investigation. After a tour of the facility, no deficiency observed.


Exit interview was conducted. Report was discussed and reviewed. The Notice of Site Visit was not posted due to tele-investigation. A copy of report will be provided through email and their signatures on this form acknowledges receipt of the report.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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