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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300656
Report Date: 08/30/2023
Date Signed: 08/30/2023 12:12:45 PM

Document Has Been Signed on 08/30/2023 12:12 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GONZALEZ,DIANA FAMILY CHILD CAREFACILITY NUMBER:
336300656
ADMINISTRATOR:GONZALEZ,DIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 565-8966
CITY:BERMUDA DUNESSTATE: CAZIP CODE:
92203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
08/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Diana GonzalezTIME COMPLETED:
12:20 PM
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On 08/30/2023, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 08/08/2023. It indicates the Child 1 (C1) suffered and injury which resulted in treatment needed by a medical professional.
Facility records were reviewed, and licensee and assistant were interviewed. Based on information gathered, the facility acted appropriately, and no violations have been identified.
Based on interviews, the facility provided first aid care to C1 and called the parent/authorized representative immediately after the incident. In addition, licensee reported the incident timely to the Department.
An exit interview was conducted and copy of this report was provided to licensee, Diana Gonzalez.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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