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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330909463
Report Date: 10/27/2021
Date Signed: 10/27/2021 02:12:25 PM

Document Has Been Signed on 10/27/2021 02:12 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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:HERNANDEZ SMALL FAMILY HOMEFACILITY NUMBER:
330909463
ADMINISTRATOR:GERI HERNANDEZFACILITY TYPE:
710
ADDRESS:1566 HEATHER LNTELEPHONE:
(951) 780-9781
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Licensee-Geri HernandezTIME COMPLETED:
02:30 PM
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On October 27, 2021, at 9:25 AM, Licensing Program Analyst (LPA) Babatunde Aborchie, met with licensee Ms. Geri Hernandez who granted access to the home. The purpose of this visit is to conduct an annual required inspection of the small family home. Presently there are five foster children in placement and five of five were present during time of inspection (See LIC 811). The home is single story with four bedrooms and three bathrooms.

Bedroom #1 has two beds, it is occupied by C1

Bedroom #2 has two beds, it is occupied by C3 and C5

Bedroom #3 has two beds, it is occupied by C2 and C4

Bedroom #4 is occupied by Licensee.

Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes, rooms are used as bedrooms, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children’s belongings. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair.



The fireplace is properly screened. All hazardous items have been properly made inaccessible to areas where children will have access. The medications are locked and stored in the kitchen cabinets. Cleansers/chemicals are locked and stored in the storage room. Sharp knives are inaccessible and stored in a locked storage. The first aid kit is in the locked closet. There are no guns or weapons as stated by Licensee at this time.
SUPERVISORS NAME: Abdoulaye Traore
LICENSING EVALUATOR NAME: Babatunde Aborchie
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ SMALL FAMILY HOME
FACILITY NUMBER: 330909463
VISIT DATE: 10/27/2021
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The hot water temperature was within normal limits. All facility smoke detectors are in appropriate working condition; fire extinguisher is properly charged and serviced. LPA interviewed two staff in the home. S2 and S3.
SUPERVISORS NAME: Abdoulaye Traore
LICENSING EVALUATOR NAME: Babatunde Aborchie
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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