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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364818501
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:57:23 PM

Document Has Been Signed on 09/07/2023 01:57 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
364818501
ADMINISTRATOR:PEREZ, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 628-9819
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
09/07/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dolores Perez TIME COMPLETED:
02:15 PM
NARRATIVE
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An unannounced case management visit was conducted by Licensing Program Analysts (LPAs) Rachel Zeron and Blanca Ruiz and met with Licensee Dolores Perez regarding an Immediate Exclusion Order for individual, Jose Antonio Flores Miranda.

During the visit, LPA Ruiz explained the details of the Immediate Exclusion Order, which was translated in Spanish at the Licensee's request. Licensee stated that Jose Antonio Flores Miranda has not been present at the facility since 05/24/2023. Licensee indicated that she understood the Immediate Exclusion Order.

Licensee was provided a copy of the Order of Individual of Immediate Exclusion, Licensee confirmed that she had a copy of the Exclusion, LPA verified that Licensee's copy was valid.
LPAs explained that the exclusion for Jose Antonio Flores Miranda was for life, he was not to return to the facility for any reason.

An exit interview was conducted, and a copy of this report was provided to the Licensee on this date. LPAs provided the Notice of Site and verified the form was posted prior to concluding the inspection.

A copy of this report must be made available to the public, at the facility site, for three (3) years.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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