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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330927502
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:51:32 AM

Document Has Been Signed on 04/10/2024 10:51 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DIAZ FAMILY DAY CAREFACILITY NUMBER:
330927502
ADMINISTRATOR/
DIRECTOR:		DIAZ, YFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 924-4846
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Ying Diaz, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit in relation to investigating complaint 10-CC-20240402130734. During the process of the complaint, LPA noted that the Licensee did not have a roster for children to present for inspection. Deficiency was cited.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC809D, and Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/10/2024 10:51 AM - It Cannot Be Edited


Created By: Jesse Gardner On 04/10/2024 at 10:10 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DIAZ FAMILY DAY CARE
FACILITY NUMBER: 330927502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
CCR
102417(g)(8)

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Operation of a Family Child Care Home:
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not being met as evidenced by:
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Licensee stated that they will complete a roster, and provide to LPA by POC date. Additionally, LPA provided a blank copy for Licensee to utilize.
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LPA requested a roster, and Licensee stated that they did not have a current roster for children in care. This presents a potential health and safety or personal rights 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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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