Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418657
Report Date: 02/06/2019
Date Signed: 02/11/2019 08:30:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GARCIA FAMILY CHILD CAREFACILITY NUMBER:
197418657
ADMINISTRATOR:GARCIA, SOILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 755-3934
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:14CENSUS: 9DATE:
02/06/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Soila GarciaTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan conducted a Case Management visit to follow up on the self reported incidents occurred at the facility on January 29, 2019 ( the telephone report was made on January 30, 2019 and the Unusual Incident/Injury Report ( LIC 624B) was mailed to El Segundo Regional Office on 02/01/2019 ) . The purpose of this visit was to discuss the incident, where a lack of care/supervision may have occurred.
An infant was trying to reach for a toy, lost her balance, hit head on the toy box/wood shelf, and sustained a bruise between eyebrows. There were five children present and two assistants observed the entire incident.

Parent (Mom) was contacted and it was suggested to take the child to the doctor. The licensee applied ice.The child returned the next day and parent did not provide a doctor's note because she did not feel child needed to go to the doctor.

During this visit, LPA interviewed the licensee and two assistants who were present at the facility during the incident. The licensee and assistants ( Thalia Vivane Solis-Duarte and Manuel Garcia) stated that they both observed the incident.

At this time based on the available information it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time of the visit with the licensee.

An exit interview was conducted; the Notice of Site Visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2019
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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