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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842698
Report Date: 07/12/2021
Date Signed: 08/26/2021 04:09:44 PM

Document Has Been Signed on 08/26/2021 04:09 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:BROOKS FAMILY CHILD CAREFACILITY NUMBER:
334842698
ADMINISTRATOR:BROOKS, LOUQUITDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 207-8320
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Louquitda Brooks-LicenseeTIME COMPLETED:
10:16 AM
NARRATIVE
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During the course of the investigation, LPA verified that an incident report was not filed with CCLD by phone within 24 hours of the incident occurring or paper form within 7 days as the required time frame by the Licensee.

Licensee stated, she did fill out the form but did not call or mail it to CCLD. Therefore (see LIC 809D for deficiency)

Exit interview conducted with Licensee and Notice of Site visit given. LPA observed posting.

Appeal rights issued and discussed.
SUPERVISORS NAME: Dawn Parker
LICENSING EVALUATOR NAME: Lakesha Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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 08/26/2021 04:09 PM - It Cannot Be Edited


Created By: Lakesha Edwards On 07/13/2021 at 09:44 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: BROOKS FAMILY CHILD CARE
FACILITY NUMBER: 334842698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited
CCR
102416.2(b)

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102416.2 (b) Reporting Requirements
(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.

This requirement was not met as evidenced by:
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Licensee has completed a LIC 624 Unusual Incident Report and will submit to CCLD. Licensee has agreed to follow Title 22 Regulations 102416.2(b) and report all future unusual incidents to CCLD within the required timeframe.
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Based on observations and interviews conducted, A child was injured in care at the facility on 6/25/2021 (hot noodles that feel over on the child burning the child leg with 2nd degree burns) and the licensee did not report the incident to Community Care Licensing within 24 hours by phone or fax.

This poses a potential risk to the health and safety of 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:Dawn Parker
LICENSING EVALUATOR NAME:Lakesha Edwards
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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