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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300775
Report Date: 05/18/2026
Date Signed: 05/18/2026 01:56:55 PM

Document Has Been Signed on 05/18/2026 01:56 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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:WOLTMAN FAMILY CHILD CAREFACILITY NUMBER:
336300775
ADMINISTRATOR/
DIRECTOR:		WOLTMAN,ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 485-1620
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 14TOTAL ENROLLED CHILDREN: 17CENSUS: 4DATE:
05/18/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Rosa WoltmanTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 05/18/2026, while conducting a complaint investigation (Complaint Control # 10-CC-20260512162650) on another matter, Licensing Program Analyst (LPA), Angelica Vargas, observed that the facility did not have a sleep log for infant C1. Additionally, LPA observed that the facility did not have immunizations record, LIC 627, LIC 995A for C1.

There are deficiencies cited on the attached 809-D pages and civil penalties were assessed for repeat violations from previous deficiency issued during annual inspection on 05/07/26.

Appeal of Rights were discussed and provided.

An exit interview was conducted with Rosa Woltman and a copy of the report was provided. Notice of site visit was provided and shall remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: Angelica Vargas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/18/2026 01:56 PM - It Cannot Be Edited


Created By: Angelica Vargas On 05/18/2026 at 12:19 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: WOLTMAN FAMILY CHILD CARE
FACILITY NUMBER: 336300775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2026
Section Cited
CCR
102425(j)(1)

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The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
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Licensee will provide a written statement of understanding daily 15min.sleep log regulation to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 05/25/2026.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that there were no daily 15min. sleep logs completed for any months since C1 started receiving services which poses a potential health, safety or personal rights risk to children in care.
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Type B
05/25/2026
Section Cited
CCR102418(g)

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(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
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Licensee will provide a written statement of understanding that all pertinent licensing forms need to be completed and signed prior to enrolling a child. Licensee will send written statement to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 05/25/2026.
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Based on observation, record review and interview, the licensee did not comply with the section cited above in that C1 did not have immunizations record nor PM286 completed which poses a potential health, safety or personal rights risk to persons 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.
Pauline Beschorner
NAME OF LICENSING PROGRAM MANAGER:
Angelica Vargas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/18/2026 01:56 PM - It Cannot Be Edited


Created By: Angelica Vargas On 05/18/2026 at 01:20 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: WOLTMAN FAMILY CHILD CARE
FACILITY NUMBER: 336300775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2026
Section Cited
CCR
102417(g)(7)

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The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to...(7)An emergency information card shall be maintained for each child and ... the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
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Licensee will provide a written statement of understanding to have LIC627 completed and signed by parent prior to providing services to children. Licensee will send statement to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 05/25/2026.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that there were no LIC 627 for C1 completed for any months since C1 started receiving services which poses a potential health, safety or personal rights risk to children in care.
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Type B
05/25/2026
Section Cited
CCR102419(d)(1)

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(d)At the time of acceptance of each child into care, the licensee shall provide the child's parent... LIC 995A ... (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A...
This requirement is not met as evidenced by:
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Licensee will provide a written statement of understanding to have LIC 995A completed and signed by parent prior to providing services to children. Licensee will send statement to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 05/25/2026.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that there was no LIC 995A for C1 completed and signed which poses a potential health, safety or personal rights risk to 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.
Pauline Beschorner
NAME OF LICENSING PROGRAM MANAGER:
Angelica Vargas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
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