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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846207
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:54:42 PM

Document Has Been Signed on 08/24/2023 02:54 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:AHLSTRAND FAMILY CHILD CAREFACILITY NUMBER:
334846207
ADMINISTRATOR:AHLSTRAND, DEVIN LEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 651-1295
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
08/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Devin Le AhlstrandTIME COMPLETED:
03:00 PM
NARRATIVE
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On 08/24/2023 at time listed above Licensing Program Analysts Giese and Zeron made an unannounced visit to the facility for another purpose. LPA met with Licensee, Devin Le Ahlstrad and was granted access to the facility.

On 02/10/2023 Licensee was issued a deficiency for criminal records clearance for an adult confirmed to reside in the home and aide in day care activities. Licensee was informed all adult residents must obtain criminal records clearance prior to initial presence in the facility.

Records reviewed at time of this visit indicate adult resident attempted to obtain criminal records clearance, however; their application and clearance was denied. Based on interview conducted with Licensee at time of this visit, Licensee confirmed above mentioned adult resident still resides in the home and was present in the off-limits, upstairs area of the home.

Based on Licensee's admission, The facility was found to be in violation of the following Title 22 regulation.

102370(d)(1) Criminal Records Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AHLSTRAND FAMILY CHILD CARE
FACILITY NUMBER: 334846207
VISIT DATE: 08/24/2023
NARRATIVE
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This is a repeat violation within one calendar year. A Civil Penalty of $3000 will be assessed during this investigation for criminal records clearance.

Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”.


LPA issued a Notice of Site Visit and verified it was posted in a prominent location at the facility. Licensees understands that the Notice of Site Visit must remain posted for the next 30 days along with a copy of all Type A deficiencies cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of child’s next day in care) given to the parents of all children enrolled in the child care facility and any children enrolled into the child care facility over the next 12 months (at the time of enrollment). Licensees are required to have all parents sign and date the Acknowledgement of Receipt of Licensing Reports (LIC9224) and maintain a copy in each child’s file. A copy of this report, LIC9224 and Appeal Rights (LIC9058) were provided during this inspection.

Exit interview conducted and report was reviewed with Licensee Devin Le Ahlstrand.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2023 02:54 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Justin Giese On 08/24/2023 at 01:52 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AHLSTRAND FAMILY CHILD CARE
FACILITY NUMBER: 334846207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/25/2023
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
This was not met as evidenced by:
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This is a repeat violation for criminal records clearance. A civil penalty of $3000 will be assessed.

Due to adult resident being unable to obtain criminal records clearance at this time, Licensee agrees to have adult resident
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Based on interview and records reviewed, adult resident was unable to obtain criminal records clearance and still resides in the home. This is an immediate health and safety risk to children in care.
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vacate premises immediately. Additionally, Licensee with submit a letter of understanding in regards to the importance and adherence of criminal records clearances. Submission due on or before POC date of 08/25/2023.

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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