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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845863
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:13:42 AM

Document Has Been Signed on 05/24/2022 10:13 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:HOLMES FAMILY CHILD CAREFACILITY NUMBER:
334845863
ADMINISTRATOR:HOLMES,ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 449-4911
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 2DATE:
05/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Ana HolmesTIME COMPLETED:
10:25 AM
NARRATIVE
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On 5/24/2022, Licensing Program Analyst (LPA) Samuel Lopez arrived at the facility to conduct an inspection/visit regarding a separate matter. In the course of the inspection LPA Lopez learned that an incident occurred that should have been reported to the Riverside Child Care Regional office, per Reporting Requirements in Title 22 regulations. Also, when LPA requested a copy of the facility roster, the licensee could not produce one.

See LIC 809-D for deficiencies

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Ana Holmes.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 05/24/2022 10:13 AM - It Cannot Be Edited


Created By: Samuel Lopez On 05/24/2022 at 09:36 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: HOLMES FAMILY CHILD CARE
FACILITY NUMBER: 334845863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
102416.2(b)

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Reporting Requirements: 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.
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Licensee agrees to submit an LIC 624B (unusual incident report) regarding the incident that occurred on 5/18/2022. Licensee agrees to submit the report to the Riverside Child Care Regional office by 5/27/2022.
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This requirement was not being met as evidenced by the licensee not reporting an incident that occurred at the facility. This poses an potential risk to the Health and Safety of the children in care.
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Type B
05/27/2022
Section Cited
CCR102417(g)(8)

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Operation of a Family Child Care Home: Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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Licensee agrees to submit a copy of the facility roster to the Riverside Child Care Regional office by 5/27/2022.
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This requirement was not being met as evidenced by the licensee not being able to produce a roster for review. This poses an potential risk to the Health and Safety of the 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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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