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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843376
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:54:05 PM

Document Has Been Signed on 03/11/2024 03:54 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PENALOZA FAMILY CHILD CAREFACILITY NUMBER:
334843376
ADMINISTRATOR:PENALOZA,KELLY & JAIMEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 818-1254
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
03/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Kelly Penaloza, LicenseeTIME COMPLETED:
04:00 PM
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On 3/11/2024 at 02:45 PM, Licensing Program Analyst (LPA) Claudia Caywood arrived at the facility to conduct a Case Management report amendment. Upon arrival, LPA was met by Licensee, Kelly Penaloza. LPA stated to the licensee the purpose of the visit.

LPA explained to the licensee that a complaint report 9099-D dated 2/21/2024 needed to be amended to reflect a page separation of the Type A and Type B Deficiency. Licensee signed amended reports and a copy was provided to the licensee, Kelly Penaloza.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to the licensee, Kelly Penaloza.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Claudia Caywood
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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