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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844818
Report Date: 12/09/2021
Date Signed: 12/09/2021 05:48:50 PM

Document Has Been Signed on 12/09/2021 05:48 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:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
334844818
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee, Patricia HernandezTIME COMPLETED:
06:00 PM
NARRATIVE
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On 12/09/21 while conducting a complaint investigation on another matter, LPA’s Sumayya Habeebulla and Linda Almaraz, observed Patricia Hernandez, Licensee, transferring 3 kids from an unlicensed home; 2869 Magellan Lane, Perris, CA 92571, to the licensed facility. The Licensee confirmed that that she did not live at the address that was licensed and was aware that she could not provide services at the unlicensed location.

See LIC809D for cited deficiencies. Appeal rights were discussed, and a copy was provided.



An exit interview was conducted, and a copy of this report was provided on this date.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 12/09/2021 05:48 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 12/09/2021 at 04:40 PM
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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited
CCR
102402(a)(1)

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The Department shall have the authority to suspend or revoke any license for the following reasons: Violation by the licensee of any of the laws, rules and regulations governing family child-care homes.
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The Licensee agreed to cease any services being provided at the unlicensed home immediately. In addition, the Licensee is to provide all parents with >>>

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This requirement was not met as evidenced by: LPA’s confirmed that the Licensee did not reside in the address that the license was issued for. This is an immediate threat to the children in care.
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>>>LIC9224- “Acknowledgement of Receipt of Licensing Reports” to all parents and submit copies to CCL by POC due date (12/10)

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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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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