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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334809549
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:01:46 PM

Document Has Been Signed on 05/16/2024 03:01 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:MARTHA'S VILLAGE & KITCHENFACILITY NUMBER:
334809549
ADMINISTRATOR/
DIRECTOR:		ROSA VERDUZCOFACILITY TYPE:
850
ADDRESS:83-791 DATE AVENUETELEPHONE:
(760) 347-4741
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 32TOTAL ENROLLED CHILDREN: 15CENSUS: 9DATE:
05/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Maria Munoz de EstevesTIME VISIT/
INSPECTION COMPLETED:
03:07 PM
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On 5/16/2024 at 2:16pm, Licensing Program Analyst (LPA) arrived at the facility to conduct a case management inspection in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 2/23/2024. It indicates that a child sustained a cut on the right side of their forehead after hitting head on the door frame. Incident occurred on 2/20/2024.

LPA toured facility and conducted interviews. Facility immediately treated wound, attempted to contact the parent and called 911 when parent could not be reached. Child returned to school without doctor restrictions. Based on information gathered, the facility acted appropriately and no violations have been identified.

An exit interview was conducted, and this report was reviewed with the facility representative Maria Munoz de Esteves. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jeanette Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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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