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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603968
Report Date: 09/15/2023
Date Signed: 09/15/2023 05:49:13 PM

Document Has Been Signed on 09/15/2023 05:49 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,
, CA
FACILITY NAME:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR:ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 204CENSUS: 48DATE:
09/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Elizabeth RosasTIME COMPLETED:
03:00 PM
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On September 15, 2023, at 1:50 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced inspection. LPA Linley met with Elizabeth Rosas, Protective Services Program Manager. The purpose of the inspection is to conduct interviews regarding a case management inspection regarding a Serious Incident Report (SIR) dated 07/272023. While at the facility, LPA received a copy of S1's employment application, S1's performance appraisal report, copy of S1's Driver's license, S1's training transcripts, S1's time sheet for 07/27/2023 and S1's Shift Report for 07/27/2023.

LPA Linley conducted one interview with one client and one interview with one staff.

Based on information gathered, further information is needed and the case management will be extended.

An exit interview was conducted and due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.
Ann Valenzuela
Charmaine Linley
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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