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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300905
Report Date: 02/01/2022
Date Signed: 03/30/2022 11:05:25 AM

Document Has Been Signed on 03/30/2022 11:05 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, 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: 20CENSUS: 7DATE:
02/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Corinne Jacobo-Seguin, LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Stacy Torrence conducted an unannounced case management inspection, in response to a self-report Unusual Incident dated 10/26/2021. LPA asked the Licensee the COVID-19 Question before entering the facility. LPA met with Corrine Jacobo-Seguin, Licensee. Census was taken. There was a total of 6 children and one infant, and two staff supervising. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The self-reported incident on 10/26/2021 disclosed a child’s personal right might be violated. During today’s inspection, LPA Torrence interviewed one staff. No children were interviewed, due to being unqualified. There were no disclosures made by staff.

Based on the interview conducted, it was determined no violation of Title 22 regulations.

Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) will be provided through email and their signatures on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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