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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300371
Report Date: 07/06/2022
Date Signed: 07/06/2022 03:19:55 PM

Document Has Been Signed on 07/06/2022 03:19 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:SHENOUDA FAMILY CHILD CAREFACILITY NUMBER:
336300371
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elva E. AguilarTIME COMPLETED:
03:30 PM
NARRATIVE
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On July 6, 2022 at 1:30PM, Licensing Program Analyst (LPA) Alaina Wilburn arrived at the facility to conduct a case management visit. Upon arrival to the facility, LPA was met by Assistant Elva E. Aguilar, who advised the licensee was out of town.

LPA briefly spoke with Licensee via the phone, but there was a connection issue. A family member communicated with licensee and confirmed licensee would not be returning until July 25, 2022. Therefore, Assistant Elva Aguilar agreed to notify parents during pick up today that the facility will be temporarily closed until the licensee returns.

In addition, licensee will contact Licensing Program Analyst upon her return, to schedule an in person Informal Conference Meeting at the Riverside South East Regional Office.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

See LIC809-D for cited deficiencies.

An exit interview was conducted, and this report was reviewed with assistant Elva Aguilar. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Alaina Wilburn
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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Document Has Been Signed on 07/06/2022 03:19 PM - It Cannot Be Edited


Created By: Alaina Wilburn On 07/06/2022 at 02:33 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: SHENOUDA FAMILY CHILD CARE
FACILITY NUMBER: 336300371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(a)
The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Wilburn's observation, the licensee did not comply with the section cited above in that the licensee went out of town and left an assistant (S1) to continue operating the day care in her absence, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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The assistant (S1) started working at the facility on 06/14/2022, and S1 has been working solo without the licensee. LPA spoke with a family member, who advised licensee will return on 07/25/2022. During pick up this evening (07/06/22), S1 agreed to inform families the facility will be temporarily closed until the licensee returns. In addition, S1 will provide parents with a copy of the Type A citation and have them complete the LIC 9224 confirming receipt of the deficiency.
Type A
Section Cited
CCR
102370(d)(2)
(d) 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:

(2) Request a transfer of a criminal record clearance as specified in Section 102370(j)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Wilburn's observation, the licensee did not comply with the section cited above in the assistant began working at the facility on 06/14/2022, but the licensee did not submit paperwork to transfer S1's criminal record clearance prior to presence in facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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S1 advised she has been live scanned, as she is an assistant at licensee's family member facility. Licensee will submit an LIC 9182, a clear current copy of S1's ID card and an LIC 508 to the CCL office, either by mail, or a copy of all required paperwork could be submitted by email at Associations_Disassociations858@dss.ca.gov. Assistant cannot be present at the
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:Stephanie Hudak
LICENSING EVALUATOR NAME:Alaina Wilburn
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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