Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012910
Report Date: 06/26/2018
Date Signed 06/26/2018 03:25:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
198012910
ADMINISTRATOR:JIMENEZ, VERONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 358-2752
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:14CENSUS: 13DATE:
06/26/2018
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Veronica Jimenez, Licensee TIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst's (LPAs) Carlos Gonzalez and Karen Chambers conducted a case management - inspection to the above facility. LPAs met with Veronica Jimenez, Licensee, who guided Analyst's on a tour of the facility at which time the census was taken and the names and ages of children present was noted. Also present was Licensee's assistant, Kristen Maldonado. LPAs observed thirteen (13) children in care at the time of inspection, four (4) of whom were infants. A facility roster was provided at the time of inspection; however, was incomplete as evidenced by names missing and birth dates.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. This notice shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted with the Licensee, during which appeal rights were explained and provided (LIC9058 01/16) The Licensee's signature on this report acknowledges receipt of her rights.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Carlos GonzalezTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2018
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198012910
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2018
Section Cited
CCR
1002417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children. Licensee did not meet this requirement as evidenced by: the facility roster provided at the time of inspection was incomplete and not updated. This was determined as the roster provided
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Licensee stated that she will update and complete the facility roster and will submit the new/updated roster to LPA by the POC due date.

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was missing children's names and birth dates. This is a potential risk to the health and safety of 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.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Carlos GonzalezTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2018
LIC809 (FAS) - (06/04)
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