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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376617364
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:02:46 PM

Document Has Been Signed on 04/26/2022 04:02 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:BROWN, LISA FAMILY CHILD CAREFACILITY NUMBER:
376617364
ADMINISTRATOR:LISA BROWNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 972-3724
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lisa Brown, LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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On April 26, 2022, at 3:00 PM, Licensing Program Analyst (LPA), Marie Hernandez conducted an unannounced case management inspection to cite the Licensee for reporting requirements. Present during the visit, are twelve children with the Licensee and the adult helper, Jezebel Figueroa. During the complaint investigation of 03/02/2022, LPA learned that the Licensee did not report the incident to the Department, that occurred on December 23, 2021. The Licensee stated she did not know she was supposed to report the incident. During today's visit of 04/26/2022 and on 03/02/2022, LPA conducted a consultation with the Licensee pertaining to reporting requirements and provided Title 22 Regulation Section 102416.2 Reporting Requirements, the Unusual Incident Report form (LIC 624-B) and the Community Care Licensing Duty Line phone number @ (619) 767-2248. The Licensee stated it was understood.

California Code of Regulations, Title 22, Section 102416.2(a)(b), is being cited on the attached LIC 809-D. LPA Marie Hernandez explained the facility evaluation report with the Licensee. A copy of the report, the notice of site visit and the appeals rights were discussed and provided to the Licensee. The Licensee was advised that the notice of site visit must be posted in a prominent place for thirty days. LPA observed the Licensee post the notice of site visit during the visit today.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Marie Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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 2
Document Has Been Signed on 04/26/2022 04:02 PM - It Cannot Be Edited


Created By: Marie Hernandez On 04/26/2022 at 01:17 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: BROWN, LISA FAMILY CHILD CARE
FACILITY NUMBER: 376617364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2022
Section Cited
CCR
1024.162(b)

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102416.2(b) Reporting Requirements - The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family childcare home. This requirement was not met as evidenced by:
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The Licensee, Lisa Brown, stated "I will report all incidents that occur in my home to the licensing office." The Licensee provided a written statement with her plan and provided the incident report.
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LPA’s records review and interview with the Licensee. The Licensee admitted to not reporting the incident of 12/23/2021 to the Department. Licensee stated she did not know she was supposed to report the incident. This poses a potential health and safety risk to children in care.
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LPA conducted a consultation with the Licensee pertaining to reporting requirements. The Licensee stated it was understood. The appeal rights were discussed and provided.

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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.
SUPERVISOR'S NAME:Cynthia Gray
LICENSING EVALUATOR NAME:Marie Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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