REPLY TO:
FACILITY NUMBER:
DATE:
ACTION TYPE:
REVIEWED BY:
FACILITY TYPE:
1.
3.
APPLICANT(S) NAME(S)
Edith Janec
Rocio Flores
Delmy Escobar
Cecilia Dunn
2.
(please print)
APPLICANT ADDRESS
11901 Dyer St
4.
5.
APPLICATION
FILED BY:
A. INITIAL APPLICATION
B. CHANGE OF CAPACITY
C. CHANGE OF LOCATION
E. CHANGE OF OWNERSHIP
F. CHANGE WITHIN CORPORATION
G. OTHER (E.G., TODDLER OPTION,
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
Sylmar
CA
91342
( 231 ) 973-3484
A.
INDIVIDUAL
B.
PARTNERSHIP
E.
COUNTY
F.
C.
G.
FACILITY/AGENCY NAME
( 818 ) 972-6662
CITY
COUNTY
11901 Dyer St
Sylmar
Los Angeles
7.
CITY
STATE
same as above
Sylmar
CA
8.
TITLE
FACILITY ADDRESS
MAILING ADDRESS
Edith Janec
TYPE OF FACILITY
A.
10.
13.
C.
OWN
RENT
17.
YES
_________
_________
PRESCHOOL
_________
_________
SCHOOL-AGE
_________
_________
MILDLY ILL
_________
_________
TOTAL CAPACITY
_________
_________
F.
19.
20.
72
TODDLER OPTION
3-5
OTHER (SPECIFY)
NO
16.
PUBLIC
PRIVATE
NAME AND FACILITY NUMBER OF OTHER COMMUNITY CARE, CHILD CARE, RESIDENTIAL CARE FACILITIES FOR THE ELDERLY, OR HEALTH FACILITIES LICENSED TO OR OWNED BY APPLICANT(S) WITHIN THE
LAST FIVE YEARS;
A.
D.
18.
91342
NO
_________
COMBINATION
15.
_________
E.
14.
INFANT
YES
AGE
RANGE:
13A.
ZIP CODE
REQUESTED
CAPACITY:
D.
SCHOOL-AGE CENTER
PROPERTY OWNERSHIP:
ZIP CODE
Board Director
9.
PROFIT CORP
AREA CODE/TELEPHONE
D.
B.
E.
C.
F.
APPLICANT(S)/LICENSEE(S) RESPONSIBILITIES:
A. IN ADDITION TO COMPLYING WITH THE HEALTH AND SAFETY CODE AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY, I / W E UNDERSTAND THAT THERE MAY BE OTHER
STATE, FEDERAL AND/OR LOCAL LAWS WHICH ARE NOT ENFORCED BY THIS AGENCY BUT THAT MAY NEED TO BE MET, SUCH AS ZONING, BUILDING, SANITATION AND LABOR
REQUIREMENTS.
B. I / W E HAVE READ AND UNDERSTAND THE STATUTES AND REGULATIONS THAT PERTAIN TO MY/OUR LICENSING CATEGORY PRIOR TO THE ISSUANCE OF MY/OUR LICENSE.
C. I / W E SHALL ENSURE THAT ALL PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL HAVE A DEPARTMENT OF JUSTICE CLEARANCE OR A CRIMINAL RECORD EXEMPTION
PRIOR TO EMPLOYMENT, RESIDENCE OR INITIAL PRESENCE IN THE FACILITY AS REQUIRED.
D. I / W E SHALL ENSURE THAT ALL PERSONS SUBJECT TO FINGERPRINT REQUIREMENTS SHALL ALSO SUBMIT A CHILD ABUSE INDEX CHECK FORM TO THE DEPARTMENT OF JUSTICE.
E. I / W E SHALL NOTIFY THE LICENSING AGENCY IMMEDIATELY IF A PERSON SUBJECT TO FINGERPRINTING REQUIREMENT, IS CONVICTED OF A CRIME AFTER EMPLOYMENT.
F. I / W E SHALL OBTAIN APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S) THAT AFFECT THE TERMS OF THE LICENSE.
I / W E UNDERSTAND THAT I / W E HAVE THE RIGHT TO APPEAL ANY DECISION REGARDING THE DISPOSITION OF THIS APPLICATION.
I / W E DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS APPLICATION AND ON THE ACCOMPANYING ATTACHMENTS ARE CORRECT TO THE BEST OF MY/OUR
KNOWLEDGE.
Board Director
Los Angeles
5/10/16
SIGNED _____________________________________________________
TITLE ________________________________________
DATE_________________
SIGNED _____________________________________________________
TITLE ________________________________________
DATE_________________
PAGE 1 OF 2
Applicant(s): Enter the name(s) of the person(s) or organization legally responsible for the facility. Enter full names.
Individuals enter first, middle and last name. If joint application, all applicants must sign this application. Individuals, each
partner, and chief executive officer or authorized representative of a firm, association, corporation, county, city, public
agency or governmental entity must complete Applicant Information (LIC 215). Corporations and other organizations also
complete Administrative Organization, (LIC 309).
2.
3.
Applicant Address: Enter legal home address of individual(s) and headquarters address of corporations. Major partner
enters principal business address. Other partners enter principal business address on Applicant Information (LIC 215).
Enter area code with telephone number.
4.
5.
Facility/Agency Name: Enter the name used to designate the single facility under application. If an agency, fill in the name of
the agency which provides the services and hyphenate the single facility name, e.g., YMCA-Peppertree Day Care School.
6.
Facility Address: Enter the address of the physical location of the facility. If applicant has more than one facility, a separate
application must be completed for each facility. Enter area code with telephone number.
7.
Mailing Address: Enter the address where all mail from the department/licensing agency should be sent.
8.
Person in Charge of Facility: Enter the name and title of person who will directly supervise the facility. If not yet employed,
enter Unknown.
9.
Type of Facility: Check the appropriate box for type of facility as defined in California Code of Regulations, Title 22.
10.
Requested Capacity and Age Range: Enter the total number of children and age range for whom care will be provided at
any time.
11.
Check box and enter number of non-ambulatory children for which you are providing care.
12.
Days & Hours of Operation: Enter days and hours of operation of facility.
13.
13A. Control of Property: If applicant(s) is leasing or renting, enter name, address and phone of owner of facility premises.
14.
Was Facility Previously Licensed? Check YES or NO. If yes, enter facility name, number and name of agency which issued
license(s).
15.
16.
Source of Water for Human Consumption: Check PUBLIC or PRIVATE water source.
17.
Other Facilities: Enter the facility name and number of any other community care or health facilities owned or operated by
applicant(s).
18.
Statement of applicant(s)/licensee(s) responsibilities of compliance with all applicable laws and regulations.
19.
20.
Signatures of all applicants or authorized person(s) (e.g., general partners of a partnership and executive officer or duly
authorized representative for all corporations, public agencies, etc.).
PAGE 2 OF 2
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
APPLICANT INFORMATION
This form must be completed by all applicants for a facility license, (i.e., all individuals, each partner in a partnership, or chief executive officer or
authorized representative in a corporation.) If more space is required, attach additional sheet. Type or print clearly.
IDENTIFYING INFORMATION
NAME
Rocio Flores
411-98-3890
TITLE
Center Director
B4578392
VALID
Yes
SEX (M/F)
Female
Yes
PLACE OF BIRTH
No
ADDRESS
EDUCATION
Circle highest completed grade:
10
11
12
DATE COMPLETED
Granada Hills High School 10535 Zelzah Avenue Granada Hills, Ca.91344
NAME AND LOCATION OF COLLEGE
COURSE STUDY
June 1995
YEARS COMPLETED
Child Develop.
GED DATE
DEGREE
DATE COMPLETED
BA
May 2009
REFERENCES
PERSONAL: (PLEASE GIVE REFERENCES, INCLUDING PRESENT AND PAST EMPLOYERS, WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY.)
NAME
ADDRESS
RELATIONSHIP
TELEPHONE
Supervisor
8184559723
Supervisor
8185564342
1.
Claudia Torres
Maricela Vasquez
Woodland Hills, Ca
2.
FINANCIAL: (PLEASE GIVE REFERENCES WITH KNOWLEDGE OF FINANCIAL RESOURCES AND BUSINESS PRACTICES.)
NAME
ADDRESS
1. Joshua Smith
Chatsworth, Ca.
2.
Patricia Rogers
RELATIONSHIP
TELEPHONE
Supervisor
8189751265
Supervisor
8187563421
HAVE YOU EVER BEEN A LICENSEE OR CO-LICENSEE OF A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY?
YES
NO
B.
YES
NO
C.
HAVE YOU EVER HELD A BENEFICIAL OWNERSHIP OF 10% OR MORE IN A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY OR BEEN AN ADMINISTRATOR, GENERAL PARTNER, CORPORATE
OFFICER, OR DIRECTOR OF ANY SUCH FACILITY?
EFFECTIVE DATES OF LICENSURE
NAME AND ADDRESS OF FACILITY
D.
FACILITY TYPE
_________________ TO __________________
A.
YES
NO
BUSINESS EXPERIENCE
NO
IF YES, COMPLETE THE FOLLOWING:
YES
Number of
Employees
Type
B.
YES
NO
Type
C.
Association Name
Date
Started
Your Title
Date
Ended
Period Held
YES
NO
Issuing Agency
Address
WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCES AND PERIODS OF
UNEMPLOYMENT IN THE LAST SEVEN YEARS. INCLUDE WORK EXPERIENCE FROM MORE THAN SEVEN YEARS, IF NECESSARY.
Dates
Basic Duties
Termination Reason
FROM
Child Care Resource Center- Head Start Responsible for the function of facility.
1/2010
TO
Current
FROM
4/2007
TO
1/2010
Pre-Kindergarten Teacher
Implementation of curiculum
Supervision of children
Kindergarten Teacher
FROM
2/2004
TO
4/2007
FROM
5/1999
TO
2/2004
Budget Cuts
FROM
TO
PERSONAL INFORMATION
A.
Do you have any physical, mental, or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure?
YES
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
DATE
5/10/16
*
Federal law (at Title 5 United States Code Section 552a Note) states that:
Any Federal, State, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether
that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.
Licensed facilities are required to have an authorized person continuously present at the facility during operational hours to
represent the facility and to accept licensing reports. Licensees shall use this form to delegate the above authority to
appropriate staff. Applicants/licensees who are corporations shall attach board resolutions authorizing this delegation.
5/10/16
Date ____________________________
Pending
Facility Number _____________________________________________________________
(818)972-6662
Phone___________________________
Los Angeles
County __________________________
Cecilia Dunn
In the event of my absence I designate ___________________________________________________________________.
He/She is
NAME
authorized to receive any documents including reports of inspections and consultations, accusations and civil and administrative
processes on my behalf at the above-named facility.
When delegating authority to appropriate staff, Residential Care Facilities for the Elderly shall comply with CCR Title 22, Division 6 Section
87564. Child Care Centers shall comply with CCR Title 22, Division 12 Section 101215.1 and other licensed facilities shall comply with
CCR Title 22, Division 6 Section 80064.
I (We) shall notify the licensing agency, in writing, within 10 days of any change in the above authorization.
________________________________________
Signature of applicants/licensees
Center Director
_____________________________________________
Title
_____________________________________________
Address
Sylmar
Los Angeles
91342
_____________________________________________
City
County
Zip
ADMINISTRATIVE ORGANIZATION
DATE
(This side is for corporations and limited liability companies only. See reverse for public agencies,
partnerships, and other associations.)
INSTRUCTIONS:
FACILITY NAME
This form must be updated and submitted to the Licensing Agency each time there is a change
in partners, officers or changes in the corporation or limited liability company as provided in the
Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).
FACILITY ADDRESS
FACILITY NUMBER
3.
Incorporation/Registration Date
2.
5.
4.
Place of Incorporation/Registration
Please attach (1) A copy of Articles of Incorporation or organization and any amendments (2) A copy of By-Laws or Operating Agreement and any
amendments (3) A copy of Resolution authorizing the filing of this application (for Corporations only).
City
Sylmar
Zip Code
91342
Title: Center Director
County
Telephone No.
Los Angeles
Address
Telephone No.:
213-973-3333
818-997-3332
Zip Code
Telephone No.
b. Please attach a copy of a foreign corporations or foreign LLCs registration to do business in California.
8. Names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC. Attach sheet for additional space.
b.
c.
d.
10. Officers: (For LLCs without officers, skip this section and go to Section II)
Office
President
Name
Edith Janec
Telephone No.
Term Expires
818-997-3332
2020
818-997-3332
2020
818-997-3332
2020
818-997-3332
2020
Rocio Flores
Cecilia Dunn
Delmy Escobar
Telephone No.
Term Expires
II.
PUBLIC AGENCY
1.
2.
Federal
State
County
City
same as above
Mailing Address: _____________________________________________________________________________________________________________
CITY/STATE/ZIP CODE
Rocio Flores
Contact Person: __________________________________
3.
Center Director
818-997-3332
Title: ___________________________________
Phone No.:_______________________
4.
III.
PARTNERSHIPS
General
Name
TELEPHONE NUMBER
Limited
2nd Partner
General
Name
TELEPHONE NUMBER
Limited
3rd Partner
General
Name
TELEPHONE NUMBER
Limited
4th Partner
General
Name
TELEPHONE NUMBER
Limited
IV.
Title: __________________________________
OTHER ASSOCIATIONS
Other associations must also provide a similar list of persons legally responsible for the organization, contact person, appropriate legal documents which set forth
legal responsibility of the organization and accountability for operating the facility.
May
FOR THE MONTH ENDING:___________________
FACILITY NAME:
APP./LIC. NO.
Monthly
PROGRAM REVENUES
19,000.00
18,516.00
Estimated
Actual
Ln #
72.00 = 1
250.00 x # _____________
Rate $ _____________
18,000.00
400.00
0.00
600.00
5.
____________________________________________________________________________________
NO
6. Total Revenue (add lines 1 through 5 and any attached). Worksheet attached?.............. YES
OPERATING COSTS
CARE AND SERVICES
7.
8.
9.
10.
11.
12.
13.
14.
15.
18,000.00
20,540.00
Estimated
Actual
19,000.00
Monthly
0.00
50.00
0.00
0.00
0.00
0.00
0.00
25.00
75.00
27
28
29
30
31
32
33
34
35
36
880.00
37. Total Operating Costs (add lines 15, 26, and 36) ...........................................................................................
37
19,405.00
38
-405.00
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
16,000.00
2,300.00
0.00
50.00
50.00
0.00
50.00
0.00
500.00
80.00
30.00
100.00
50.00
20.00
50.00
50.00
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
TITLE:
APPLICANT/LICENSEE SIGNATURE:
18,450.00
DATE:
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
27.
28.
29.
30.
31.
32.
33.
34.
35.
GENERAL ADMINISTRATION
Staff salaries and wages (verified to staffing report).
Federal and state payroll taxes and the cost of employee benefits including workers compensation insurance incurred by the
facility.
Direct transportation costs, (Include vehicle loan payments, maintenance and fuel).
Include all costs for telephone communications (phones, FAX, pagers, etc.).
Costs for office supplies and postage.
Costs for business related advertising.
Costs for business licenses, membership fees and professional fees.
All contract to labor.
Costs for all other insurance (public liability, property damage, auto, surety bond, etc.).
Costs/Expenses required for the support of a corporate or headquarters office.
PHYSICAL PLANT
Cost to rent, lease or mortgage payments on the facility.
Costs for real estate property taxes (average monthly cost).
Costs for natural or propane gas used in the facility.
Costs for electricity consumed at the facility.
Costs for water, including bottled water.
Costs for disposal of garbage.
Costs for building repair and maintenance.
Costs for furniture and equipment repair and maintenance.
All other expenses.
SIGNATURE BLOCK
The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this form attesting
to the financial information. Failure to sign, date and attest to the accuracy of the information reported on the Monthly Operating
Statement (LIC 401) shall constitute non-compliance and the rejection of this report.
BALANCE SHEET
IMPORTANT
Before completing, see reverse for
instructions.
Attach LIC 403a.
FACILITY NAME:
ENTITY NAME:
APP./LIC. NO.
3,000
Cash on hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________
2.
52,000
______________________
3.
5,000
______________________
4.
0
______________________
5.
0
______________________
6.
0
______________________
7.
60,000
7 $ __________________
LONG-TERM ASSETS
8.
0
Real Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________
9.
0
______________________
10. Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
11. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10,000
______________________
8,000
______________________
______________________
14. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
15. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
16. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
17.
18,000
17 $ __________________
78,000
$ __________________
5,900
19. Credit Accounts (open, revolving and installment) . . . . . . . . . . . . . . $ ____________________
20. Salaries & Wages Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16,000
______________________
______________________
______________________
23. Mortgages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
______________________
______________________
______________________
__________________
21,900
27 $ __________________
28 $ __________________
EQUITY
28. Equity
56,100
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
TITLE:
APPLICANT/LICENSEE SIGNATURE:
DATE:
PAGE 1 OF 2
BALANCE SHEET
GENERAL INFORMATION: To complete the Balance Sheet LIC 403, first complete the LIC 403a, Balance Sheet Supplemental
Schedule. The LIC 403a is a worksheet to be used in compiling the detailed information which is then totaled and displayed on the Balance
Sheet, LIC 403. Submit the LIC 403a attached to the LIC 403.
Each applicant/licensee (sole proprietorship, partnership or corporation) must submit a LIC 403, and a LIC 403a. Information to be
reported is to disclose all the entitys assets and liabilities, not just those related to the operation of the care facility.
FOR SOLE PROPRIETORSHIPS - For a facility operated by a husband or wife individually, information reported must pertain to both, such
as individual credit card balances which are listed either solely under one name or under both the husband and wife, and which may be
unrelated to the facilitys actual operation or the person who will actually operate the facility.
FOR GENERAL PARTNERS - In addition to financial statements for the partnership, each general partner must file a personal Balance
Sheet, LIC 403, accompanied with a LIC 403a, to reflect their individual financial position.
Information shown on the LIC 403 and LIC 403a is subject to verification. Additional documentation may be requested to support any
or all of the Balance Sheet amounts reported.
INSTRUCTIONS: Include the required information at the top of this form to identify: 1) current date for the Balance Sheet, 2) entity name,
(this is the sole proprietorship, partner, partnership or corporate name for whom the information is being reported) 3) facility name and 4)
application/license number. Transfer the totals from the worksheet LIC 403a to the corresponding lines on the LIC 403. Below is a brief
description of the type of information to be contained on each line.
ASSETS
Line #
1.
Cash on hand, not deposited in a financial institution.
2.
Cash in checking accounts.
3.
CDs, savings account(s) and all other like accounts.
4.
Revenues receivable and all short-term notes receivable (less than one year).
5.
Stocks, bonds or other securities.
6.
Other current assets readily converted to cash, such as the cash surrender value of whole life insurance policies.
7.
Add the amounts on lines 1 through 6 and enter here.
8.
Real property is buildings, land and structures.
9.
Land (developed or undeveloped) not already included on line 8.
10. Improvements to real property or leasehold improvements as appropriate.
11. Business or personal equipment, (other than that being leased).
12. Business or personal furniture and fixtures, as appropriate, (other than that being leased).
13-16. Other Long-Term Assets (Autos, motor homes inventory, etc.)
17. Add the amounts reported on lines 8 through 16 and enter here.
18. Add the amounts on line 7 and line 17 and enter here.
LIABILITIES
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
The equity is the difference between your total assets and total liabilities. Subtract line 27 from line 18 and enter here.
SIGNATURE BLOCK
The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this form attesting
to the financial information. Failure to sign, date and attest to the accuracy of the information reported on the Balance Sheet
(LIC 403) shall constitute non-compliance and the rejection of this report.
PAGE 2 OF 2
NOTE:
FINANCIAL INFORMATION
RELEASE AND VERIFICATION
I.
TO BE COMPLETED BY APPLICANT(S)
Edith Janec,
I/WE______________________________________________________________________________________________________________
NAME(S)
(PLEASE PRINT)
Wells Fargo
HEREBY AUTHORIZE _______________________________________________________________________________________________
(NAME OF BANK OR FINANCIAL INSTITUTION)
North Hills
91335
13814 Woodley Ave
CA
_________________________________________________________________________________________________________________
(ADDRESS)
(CITY)
(STATE)
(ZIP CODE)
TO GIVE INFORMATION ON THE FOLLOWING ACCOUNT(S) TO LICENSING AGENCY IN SECTION II BELOW FOR UP TO ONE YEAR
FROM THE DATE OF MY SIGNATURE.
DATE
11901 Dyer St
II.
CITY/STATE/ZIP CODE
FACILITY NAME
PERSONAL
Yes
No
TYPE OF LOAN
SECUREDLOAN NUMBER
DATE LOAN
OPENED
DATE OF FIRST
LOAN PAYMENT
UNSECUREDLOAN NUMBER
DATE LOAN
OPENED
DATE OF FIRST
LOAN PAYMENT
Yes
BUSINESS
ACCOUNT NUMBER(S)
PRESENT BALANCE
PRESENT BALANCE
CREDIT LIMIT
AVAILABLE BALANCE
MINIMUM PAYMENT
$
Yes
No
Yes
No
AS OF (DATE)
IS ACCOUNT SATISFACTORY
IS ACCOUNT SATISFACTORY
Yes No
(If No, explain in
the Remarks Section below).
Yes No
(If No, explain in
the Remarks Section below).
REMARKS:
TITLE
TELEPHONE NUMBER
DATE
INSTRUCTIONS:
PERSONNEL REPORT
NAME OF FACILITY
This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility,
including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for
specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential
facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing
Agency and retain copy in facility file.
FACILITY TYPE
FACILITY NUMBER
PREPARED BY
DATE
5/10/2016
Edith Janec
A.
STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and
1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.
NAME
Licensee/Administrator
DATE
EMPL'D
JOB TITLE
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
Edith Janec
2015
Teacher
M-F
715
345
Rocio Flores
2015
Site Director
M-F
900
530
Delmy Escobar
2015
Teacher
M-F
800
330
Cecilia Dunn
2015
Teacher
M-F
930
600
Pending
2015
Assistant
M-F
715
345
Pending
2015
Assistant
M-F
930
600
Pending
2015
Assistant
M-F
900
330
Pending
2015
Assistant
M-F
930
400
Pending
2015
Assistant
M-F
8:30
1230
Pending
2015
Assistant
M-F
1:15
5:15
Pending
2015
Office Clerk
M,W,F 730
1130
Pending
2015
Housekeeper
M-F
310
640
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
4/2007 1/2010
T, TH
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
2/2004 04/2007
200
Page 1 of 2
B.
STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09,
1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background
check requirements pursuant to statute.
NAME
DATE
EMPL'D
JOB TITLE
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
SPECIFY
DAYS AND HOURS ON DUTY
DAYS
FROM
TO
Page 2 of 2
DATE
PERSONNEL RECORD
5/10/16
NAME OF FACILITY
Pending
1.
NAME (LAST
FIRST
Flores
PERSONAL
TELEPHONE
MIDDLE)
Rocio
Carolina
(818 ) 972-2314
ADDRESS
411
98
3890
B4578392
_____________________________
1/11/16
YES
YES
1/13/16
NO
NO
CDL NUMBER
NEAREST LIVING RELATIVE NAME:
Carolina Flores
(818) 434-8901
YES
NO
RELATIONSHIP
Mother
ADDRESS
POSITION
TITLE
SALARY
HOURS
$4,000.00 monthly
Center Director
$25.00
DATE OF EMPLOYMENT
Pending
NAME OF SUPERVISOR
3.
PREVIOUS EMPLOYMENT
(List most recent experience first. If additional space is needed, please attach a separate page.)
TELEPHONE
JOB TITLE AND
DATES
REASON FOR
NAME AND ADDRESS OF EMPLOYER
NUMBER
FROM
TO
TYPE OF WORK
LEAVING
(818)717-1000
Center Director/Teacher
Current
(818)368-8442
Pre-K Teacher
Professional
4/2007
1/2010
(818)766-5557
Kindergarten Teacher
Professional
2/2004
04/2007
(818)774-2840
5/1999
2/2004
4.
CIRCLE HIGHEST YEAR COMPLETED
10
11
12
EDUCATION
DIPLOMA
High School
NO
(OVER)
NUMBER
CURRENTLY
DATE
UNITS
COMPLETED COMPLETED ENROLLED
4.
EDUCATION (Continued)
MAJOR
SUBJECT
NO. OF
YEARS
COMPLETED
NO. OF
UNITS
COMPLETED
BA
Child Devlop 4
5.
DIPLOMA
DEGREE OR
DATE
CERTIFICATE COMPLETED
May 2009
REFERENCES
List names of three persons who can give information about your background, character, abilities, etc.
NAME
ADDRESS
TELEPHONE
NUMBER
RELATIONSHIP TO YOU
(FRIEND, EMPLOYER, ETC.)
Elidia Anaya
(818)638-8390
Co-worker/Lead Teacher
Marcy Robles
(818)772-3329
Supervisor/Center Director
Maricela Gonzalez
(818)787-0230
Co-Teacher/TA
6.
NOTES:
I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification.
SIGNATURE OF EMPLOYEE
DATE
FACILITY NAME
PERSON'S NAME
AGE
Rocio Flores
38
POSITION TITLE
TYPE OF FACILITY
Center Director
Preschool
DUTY STATEMENT
Responsible for the supervision of the daily function of the center including the care and safety of the children and staff.
Ensure that center is in compliance with licensing and standards followed by the program.
TYPES OF PERSONS SERVED (Check appropriate items)
Infants
Adults
Children
Elderly
Developmentally Disabled
Mentally Disordered
Physically Handicapped
Drug/Alcohol Addiction
Children with developmental disabilities based on assessments and Individual Education Plan(IEP)
Other (specify) ______________________________________________________________________________________________
DATE
1/13/15
NOTE TO PHYSICIAN: Personnel in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be free from
communicable disease, and capable of performing assigned tasks. Please complete the following information on the above named person.
Patient is able to conduct job duties physically and mentally based on job position of Center Director.
NOTE ANY HEALTH CONDITION THAT WOULD CREATE A HAZARD TO THE PERSON, CLIENTS, CHILDREN OR OTHER PERSONNEL
N/A
1/13/15
DATE OF HEALTH SCREENING
POSITIVE
NEGATIVE
NAME OF PHYSICIAN (PHYSICIANS STAMP)
DATE
TELEPHONE #
DATE
1/11/15
(818)719-2000
1/13/15
YES
NO
You need not disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code
sections 11361.5 and 11361.7.
Have you ever been convicted of a crime from another state, federal court,
military or jurisdiction outside of U.S.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
Criminal convictions from another State or Federal court are considered the same as criminal convictions in California.
If you answer YES, give details on the back of this page indicating the nature and circumstances of each crime and the
date and the location in which each crime occurred.
You must disclose convictions, including reckless and drunk driving convictions even if:
1.
2.
3.
4.
5.
6.
NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT DISCLOSE
ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) WILL RESULT IN AN EXEMPTION
DENIAL.
I declare under penalty of perjury under the laws of the State of California that I have read and understand
the information contained in this affidavit and that my responses and any accompanying attachments are
true and correct.
YOUR NAME (PRINT CLEARLY)
YOUR ADDRESS
CITY
Rocio Flores
DATE OF BIRTH
411-98-3890
SIGNATURE
05/05/1979
ZIP
91345
B4578392
DATE
05/10/2016
PAGE 1 OF 2
I.
Instructions to Respondents:
If you have been convicted of a crime in California, another state or in federal court, provide the following
information:
(You need not disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety
Code sections 11361.5 and 11361.7.)
I certify under penalty of perjury that the above information is true and correct to the best of my knowledge.
05/10/2016
Signature ____________________________________________ Date ____________________
II. Instructions to the Office of the Long-Term Care Ombudsman:
If the person discloses a criminal conviction, review the persons statement. Maintain this form in your personnel file
and send a copy to the Caregiver Background Check Bureau, 744 P Street, MS 9-15-62, Sacramento, CA 95814.
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798
et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department
of Justice uses a persons SSN as an identifying number. The requested SSN is voluntary. Failure to provide the
SSN may delay the processing of this form and the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871) The Department will
create a file concerning your criminal background check that will contain certain documents, including information that
you provide. You have the right to access certain records containing your personal information maintained by the
Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have
to provide copies of some of the records in the file to members of the public who ask for them, including newspaper
and television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if some one in a licensed facility has a
criminal record exemption. The Department must also tell people who ask, the name of a licensed facility that has a
licensee, employee, resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
LIC 508B (3/11) REQUIRED FORM - NO CHANGE PERMITTED
PAGE 2 OF 2
INSTRUCTIONS:
Post a copy in a prominent location in facility, near telephone.
Licensee is responsible for updating information as required.
Return a copy to the licensing office.
NAME OF FACILITY
ADMINISTRATOR OF FACILITY
(NUMBER,
Rocio Flores
STREET,
CITY,
I.
STATE,
Sylmar
Ca.
ZIP CODE)
91342
TELEPHONE NUMBER
( 818 ) 972-6662
1. Rocio Flores
Center Director
2. Cecilia Dunn
Teacher
3. Edith Janec
Teacher
Teacher
TRANSPORTATION
4.
Delmy Escobar
6.
II.
POLICE OR SHERIFF
RED CROSS
POISON CONTROL
HOSPITAL(S)
III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
1. See Evacuation Maps Posted in each room
2.
3.
4.
IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASSOR/MANAGER/PROPERTY OWNER)
NAME
ADDRESS
TELEPHONE NUMBER
ADDRESS
TELEPHONE NUMBER
( 818 ) 459-2378
(
V.
UTILITY SHUTOFF LOCATIONS (INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
ELECTRICITY
Inside of each classroom including the office room and outside inside of the storage shed.
VII. EQUIPMENT
SMOKE DETECTOR LOCATION (IF REQUIRED)
DATE
DATE:
5/10/16
APPLICANT NAME:
Rocio Flores
FACILITY NAME:
As part of the application process, the licensing agency is responsible for obtaining a fire safety
inspection from the local fire inspection authority having jurisdiction in the area where your facility is
located.
To help us expedite this process, we are requiring that you identify the local fire inspection authority that
is responsible to inspect your facility and issue a fire clearance.
LOCAL FIRE INSPECTION AUTHORITY:
B.
CHILDREN:
PARENTS:
Identify and assign individual responsibilities for staff following an earthquake (including accounting for and evacuating children,
Involve and train all staff members about the earthquake safety plan, including location and procedure for turning off utilities and
gas.
Contact nearby agencies (including police, fire, Red Cross, and local government) for information and materials in developing the
child care earthquake safety plan.
(2)
(3)
Red Cross
ADDRESS:
ADDRESS: