Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300901
Report Date: 05/10/2017
Date Signed: 05/10/2017 12:25:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:TRAN-BELLEBILLE, PATRICIAFACILITY NUMBER:
304300901
ADMINISTRATOR:TRAN-BELLEVILLE, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 891-6918
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:14CENSUS: 8DATE:
05/10/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Patricia Tran-BellevilleTIME COMPLETED:
12:45 PM
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An inspection was conducted at the facility, by LPA Dean Valencia. The inspection was conducted to verify that an A violation cited on 4/25/2017, for having 5 infants in care, was corrected. During the inspection, it was verified that the A violation has been corrected. There were 8 children in care, 2 of whom were infants. An adult assistant was present providing care as well. There were no deficiencies observed during today's inspection. As of today, 5/10/2017, the A violation for operating out of ratio on 4/25/2017 has been corrected.

Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2017
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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