Merged 1

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR A CHILD CARE CENTER LICENSE

(See Instructions on Back)
REPLY TO:
FOR DEPARTMENT USE ONLY

DISTRICT:
COUNTY:
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:
REQUESTED ACTION (CHECK ONE):
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,
D. CHANGE OF FACILITY TYPE
COMBINATION CENTER, ETC.)
CITY
STATE
ZIP CODE
AREA CODE/TELEPHONE
Sylmar
CA
91342
( 231 ) 973-3484
A.
INDIVIDUAL
B.
PARTNERSHIP
E.
COUNTY
F.
OTHER PUBLIC AGENCY
C.
NON PROFIT CORP.
G.
LIMITED LIABILITY COMPANY
EMAIL (NOT REQUIRED)
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
PERSON IN CHARGE OF FACILITY
Edith Janec
TYPE OF FACILITY
A.
10.
INFANT CARE CENTER
CHECK HERE FOR TODDLER OPTION

B.
13.
C.
OWN
RENT
17.
YES
_________
_________
PRESCHOOL
_________
_________
(CHECK APPROPRIATE BOXES FOR COMBINATION

CENTER)
SCHOOL-AGE
_________
_________
MILDLY ILL
_________
_________
TOTAL CAPACITY
_________
_________
F.
19.
20.
72
CHILDREN, CHECK HERE:
TODDLER OPTION
3-5
NUMBER OF NON-AMBULATORY ___________
12. DAYS AND HOURS OF OPERATION:

(IF A COMBINATION CENTER IS CHECKED, ENTER
DAYS AND HOURS FOR EACH COMPONENT.)
OTHER (SPECIFY)
OTHER (SPECIFY) __________________________________________________________________________________
NO
LICENSING AGENCY NAME:
DATE CONSTRUCTION TO BEGIN: _____________________________________________

DATE TO BE COMPLETED: ___________________________________________________
16.
SOURCE OF WATER FOR HUMAN CONSUMPTION
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
IS MAJOR CONSTRUCTION REQUIRED?
_________
COMBINATION
WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:
15.
_________
E.
14.
INFANT
IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:
YES
AGE
RANGE:
CHILD CARE CENTER FOR MILDLY ILL CHILDREN
13A.
ZIP CODE
11. IF PROVIDING CARE TO NON-AMBULATORY
REQUESTED
CAPACITY:
D.
SCHOOL-AGE CENTER
PROPERTY OWNERSHIP:
ALTERNATIVE PUBLIC TELEPHONE
CHILD CARE CENTER (PRE-SCHOOL)
CHECK HERE FOR TODDLER OPTION
ZIP CODE
Board Director
9.
PROFIT CORP
AREA CODE/TELEPHONE
Early Learning Bilingual Academy

6.
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 ________________________________________
COUNTY WHERE SIGNED ______________________________
DATE_________________
SIGNED _____________________________________________________
TITLE ________________________________________
COUNTY WHERE SIGNED ______________________________
DATE_________________
LIC 200A (6/08)
PAGE 1 OF 2
INSTRUCTIONS FOR APPLICATION FOR A CHILD CARE CENTER LICENSE
Type or print clearly. Prepare application in duplicate. Return original.

1.
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.
Requested Action: Check appropriate box.
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.
Application Filed by: Check appropriate box.
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.
Property Ownership: Check the appropriate box.
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.
Is Facility to be Constructed or Require Major Building Change? Self-explanatory.
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.
Acknowledgement of right to appeal.
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.).
LIC 200A (6/08)
PAGE 2 OF 2
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY

COMMUNITY CARE LICENSING DIVISION
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
SOCIAL SECURITY NUMBER

(VOLUNTARY FOR I.D. ONLY)
Rocio Flores
411-98-3890
TITLE
DRIVERS LICENSE NUMBER
Center Director
B4578392
VALID
Yes
SEX (M/F)
ARE YOU 18 YEARS OR OLDER?
Female
Yes
PLACE OF BIRTH
No
California, Los Angeles

(AREA CODE) TELEPHONE NUMBER
( 818 ) 972-6662
ADDRESS
11901 Dyer Street Sylmar, Ca. 91342

OTHER NAME(S) USED BY APPLICANT
EDUCATION
Circle highest completed grade:
10
11
12
NAME AND LOCATION OF HIGH SCHOOL
DATE COMPLETED
Granada Hills High School 10535 Zelzah Avenue Granada Hills, Ca.91344
NAME AND LOCATION OF COLLEGE
COURSE STUDY
California State University Northridge
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
Misssion Hills, Ca.
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.
Sherman Oaks, Ca.
Patricia Rogers
RELATIONSHIP
TELEPHONE
Supervisor
8189751265
Supervisor
8187563421
PRIOR LICENSURE STATUS

A.
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
IF YES,, COMPLETE C AND D BELOW.
B.
YES
NO
IF YES, COMPLETE C AND D BELOW:
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.
WERE ANY DISCIPLINARY ACTIONS TAKEN?
FACILITY TYPE
_________________ TO __________________
A.
YES
NO
HAVE YOU OWNED OR OPERATED ANY BUSINESS?
BUSINESS EXPERIENCE
NO
IF YES, COMPLETE THE FOLLOWING:
YES
Number of
Employees
Type
B.
IF YES, PLEASE EXPLAIN:
DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE?
YES
NO
Type
C.
ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION?
Association Name
LIC 215 (7/04) (PERSONAL)
Date
Started
Your Title
Date
Ended
Period Held
YES
Reason for End
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
Name and Address of Employer
Basic Duties
Termination Reason
FROM
Child Care Resource Center- Head Start Responsible for the function of facility.
Seeking professional growth
1/2010
TO
Current
Center Director and Lead Teacher
Supervision of employees & customers. Become a business owner
17453 Prairie St. Chatsworth Ca, 91311
Monitor licensing/standards compliance
FROM
KinderCare- Knowledge Learning Center Care and supervision of children
Professional Growth Opportunity
4/2007
TO
1/2010
Pre-Kindergarten Teacher
Implementation of curiculum
14321 Rinaldi St. Granada Hills, 91344
Conduct Assessments for children
ABC Little School
Supervision of children
Kindergarten Teacher
Follow curiculum and lesson planning
11728 Moorpark St. Studio City 91604
Prepare children for Elementary School
FROM
Professional Growth Opportunity
2/2004
TO
4/2007
FROM
5/1999
TO
2/2004
WestValley YMCA Woodlake Elementary Responsible for daily function of center

Assistant Director/ Counselor
Care and supervision of children/staff
18810 Vanowen St. Reseda 91335
Monitor licensing/standards compliance
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
If yes, please explain:

NO
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
COUNTY WHERE SIGNED
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.
STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

COMMUNITY CARE LICENSING
DESIGNATION OF FACILITY RESPONSIBILITY
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.

Facility Name _______________________________________________________________
5/10/16
Date ____________________________
Pending
Facility Number _____________________________________________________________
11901 Dyer Street

Facility Address _____________________________________________________________
(818)972-6662
Phone___________________________
Sylmar, Ca. 91342

City ______________________________________________________________________
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
11901 Dyer Street
_____________________________________________
Address
Sylmar
Los Angeles
91342
_____________________________________________
City
County
Zip
LIC 308 (11/02) (PUBLIC)

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
I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)

1.
Name (as filed with Secretary of State)
3.
Incorporation/Registration Date
2.
Chief Executive Officer
5.
4.
Place of Incorporation/Registration
Corporation/Limited Liability Company Number
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).
6. Principal office of business:

Address
City
11901 Dyer St.
Sylmar
Contact Person: Rocio Flores

7. Out of state or foreign applicants complete the following:
a. Name of California Representative
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.
9. Directors (Corporation)/Managers and Managing Members (LLC)

a.
Number of Directors/Managers & Managing Members
b.
Term of Office (if applicable)
c.
Frequency of Meetings (if applicable)
d.
Method of Selection (corporations only)
10. Officers: (For LLCs without officers, skip this section and go to Section II)
Office
President
Name
Edith Janec
Principal Business Address & City & Zip Code

(other than facility address)
11570 Wheeler Ave
Telephone No.
Term Expires
818-997-3332
2020
818-997-3332
2020
818-997-3332
2020
818-997-3332
2020
Sylmar, CA. 91342

Vice-President
Rocio Flores
11570 Wheeler Ave
Sylmar, CA. 91342

Secretary
Cecilia Dunn
11570 Wheeler Ave
Sylmar, CA. 91342

Treasurer
Delmy Escobar
11570 Wheeler Ave

Sylmar, CA. 91342
LIC 309 (6/01) (PUBLIC)
11. List all Directors (Corporations)/Managers and Managing Members (LLC)

Name
Mailing Address & City & Zip Code
Telephone No.
Term Expires
(Attach Sheet for additional space)
II.
PUBLIC AGENCY
1.
Check type of public agency:
2.
Agency providing services:
Federal
State
Learning Bilingual Academy

Name: Early
_______________________________________________
County
City
Other, specify below
11901 Dyer St. Sylmar, CA. 91342

Address: ___________________________________________________________
CITY/STATE
same as above
Mailing Address: _____________________________________________________________________________________________________________
CITY/STATE/ZIP CODE
Rocio Flores
Contact Person: __________________________________
3.
District or Area to be served:
Center Director
818-997-3332
Title: ___________________________________
Phone No.:_______________________
(attach map if necessary)
Specify geographic area:
4.
Attach copy of Resolution or legal document authorizing this application.
III.
PARTNERSHIPS
Attach a copy of partnership agreement (attach additional sheet if necessary)

1st Partner
General
Name
TELEPHONE NUMBER
Limited
Principal Business Address

CITY/STATE
2nd Partner
General
Name
TELEPHONE NUMBER
Limited

CITY/STATE
3rd Partner
General
Name
TELEPHONE NUMBER
Limited

CITY/STATE
4th Partner
General
Name
TELEPHONE NUMBER
Limited

CITY/STATE
Contact Person: _______________________________
IV.
Title: __________________________________
Telephone No.: ___________________
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.

MONTHLY OPERATING STATEMENT
IMPORTANT - Before completing,

see reverse for instructions.
May
FOR THE MONTH ENDING:___________________
FACILITY NAME:
APP./LIC. NO.

FACILITY ADDRESS:
Monthly
11901 Dyer St. Sylmar, CA. 91342

OPERATING REVENUES
Ln #
PROGRAM REVENUES
1. SSI Revenue (Monthly SSI Rate) x (Number of SSI Clients)
19,000.00
18,516.00
Estimated
Actual
2. Voluntary 3rd Party Contributions

3. Private Revenue
Ln #
72.00 = 1
250.00 x # _____________
Rate $ _____________
Number of Private Pay Residents # ______________
18,000.00
400.00
0.00
600.00
OTHER REVENUES RELATED TO THE FACILITY

4.
Spanish Lessons - Saturday

____________________________________________________________________________________
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. Net Profit (Loss) (subtract line 37 from 6).......................................................................................................
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
Food Costs .....................................................................................................................................................

Household Supplies .......................................................................................................................................
Laundry and Dry Cleaning .............................................................................................................................
Personal Hygiene Items .................................................................................................................................
Recreational Activities ....................................................................................................................................
Newspapers, Magazines, Cable TV ...............................................................................................................
Medical and First Aid ......................................................................................................................................
Client Transportation ......................................................................................................................................
Total Care & Services (add lines 7 through 14)........................................................................................
GENERAL ADMINISTRATION
Salaries and Wages .......................................................................................................................................
Payroll Taxes and Employee Benefits.............................................................................................................
General Transportation...................................................................................................................................
Telephone .......................................................................................................................................................
Office Supplies ...............................................................................................................................................
Advertising......................................................................................................................................................
Fees for licenses and memberships ...............................................................................................................
Contract Labor................................................................................................................................................
Insurance (Liability and Fire) ..........................................................................................................................
Indirect Overhead ...........................................................................................................................................
Total General Administration (add lines 16 through 25) ...........................................................................
PHYSICAL PLANT
Rent, Lease, Mortgage Payments and Homeowners Association Fees.........................................................
Property Taxes ...............................................................................................................................................
Gas .................................................................................................................................................................
Electricity ........................................................................................................................................................
Water ..............................................................................................................................................................
Garbage .........................................................................................................................................................
Repair & Maintenance (Building)....................................................................................................................
Repair & Maintenance (Furniture & Equipment) ............................................................................................
Other (specify) ................................................................................................................................................
Total Physical Plant (add lines 27 through 35) .......................................................................................
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:
LIC 401 (3/01)
TITLE:
APPLICANT/LICENSEE SIGNATURE:
18,450.00
DATE:
MONTHLY OPERATING STATEMENT

GENERAL INFORMATION AND INSTRUCTIONS
GENERAL INFORMATION - Each applicant/licensee (sole proprietorship, partnership, corporation or limited liability company) must
submit a LIC 401, OPERATING STATEMENT, for care facilities in operation or pending (to commence within the next twelve months). In
addition, an LIC 401a, Supplemental Financial Information, Part II must be submitted. A separate LIC 401 is to be submitted for each CCLD
licensed/pending license operation. A profit and loss statement is to be submitted for other business operations. For CCLD operations
already licensed or other ongoing business operations the reported amounts are to be actual rather than estimated. For CCLD operations
pending license or other pending business operations the reported amounts may be estimated.
FOR INDIVIDUALS AS SOLE PROPRIETORS - Part I of the LIC 401a must also be completed.
FOR GENERAL PARTNERS - In addition to the LIC 401a, Part II, for the partnership a separate Form LIC 401a must be completed for
each general partner. Information reported on this document is subject to verification. Therefore, additional documentation may be
requested to support some or all of the items reported.
INSTRUCTIONS Please include the required information at the top of this form to identify the 1) reporting period of the information,
2) facility name, 3) facility address and 4) application or license number.
REVENUES
Line # PROGRAM REVENUES
1. Report the SSI monthly rate, the number of clients/residents and the total monthly revenue.
2. Report all 3rd party voluntary contributions received on behalf of all SSI recipients.
3. Report average monthly rate for private pay clients/residents, the number of private pay clients/residents and the total
monthly revenue.
OTHER REVENUES
4-5. Report all other facility related revenues (i.e. interest income, subleases, insurance reimbursements, sale of assets)
individually on lines 4 and 5. If more space is required attach a worksheet and indicate the total on line 5.
OPERATING COSTS
CARE AND SERVICES
7. Costs for food products, and meals for clients, residents and staff.
8. Costs for cleaning supplies (except laundry and dry cleaning).
9. Costs for laundry and dry cleaning.
10. Costs for personal hygiene items provided for the clients and residents.
11. Costs for recreational activities.
12. Costs for newspapers, magazines, cable TV, etc.
13. Costs for medical supplies, first aid, and any other non-reimbursable medical costs.
14. Costs for transporting clients/residents to and from medical appointments, recreational activities, and other allowable
transportation costs.
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
May 20, 2016

As of__________________________
(ENTER CURRENT DATE)
IMPORTANT
Before completing, see reverse for
instructions.
Attach LIC 403a.
FACILITY NAME:
ENTITY NAME:
APP./LIC. NO.

ASSETS
CURRENT ASSETS
1.
3,000
Cash on hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________
2.
Cash in Financial Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52,000
______________________
3.
CDs & Other Like Accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5,000
______________________
4.
Short-Term Receivables & Notes . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
5.
Stocks & Bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
6.
Other Current Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
7.
TOTAL CURRENT ASSETS
(add lines 1 through 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60,000
7 $ __________________
LONG-TERM ASSETS
8.
0
Real Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________
9.
Land (other than included in above) . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
10. Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
______________________
11. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10,000
______________________
12. Furniture & Fixtures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8,000
______________________
13. Other Long-Term Assets: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
14. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
15. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
16. ______________________________ . . . . . . . . . . . . . . . . . . . . . . .
______________________
17.
TOTAL LONG-TERM ASSETS
18. TOTAL ASSETS
18,000
(add lines 8 through 16) ........................................................
17 $ __________________
(add lines 7 and 17) ..............................................................
78,000
$ __________________
LIABILITIES AND EQUITY

LIABILITIES
5,900
19. Credit Accounts (open, revolving and installment) . . . . . . . . . . . . . . $ ____________________
20. Salaries & Wages Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16,000
______________________
21. Taxes Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
22. Other Payables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
23. Mortgages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
24. Auto Loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
25. Equipment Loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
26. Other Notes Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
______________________
27. TOTAL LIABILITIES
__________________
(add lines 19 through 26) . . . . . . . . . . . . . . . . . . . . . . . . . . .
21,900
27 $ __________________
(subtract line 27 from line 18) . . . . . . . . . . . . . . . . . . . . . . .
28 $ __________________
EQUITY
28. Equity
56,100
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
LIC 403 (7/11)
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.
Credit Accounts (Open, Revolving and Installment).

Salaries, wages, bonuses and other benefits payable.
Federal, state or local income, sales or payroll taxes.
Other notes or payables not included above.
Current balances for all of the outstanding mortgages.
Vehicle loans.
Loans payable for furniture and equipment.
Other long-term notes or payables.
Add the amounts on lines 19 through 26 and enter here.
EQUITY
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.
LIC 403 (7/11)
PAGE 2 OF 2

NOTE:
FINANCIAL INFORMATION
RELEASE AND VERIFICATION
I.
APPLICANT(S) COMPLETES SECTION I ONLY AND RETURNS

WITH APPLICATION TO LICENSING AGENCY. A SEPARATE LIC 404
IS REQUIRED FOR EACH BANK/FINANCIAL INSTITUTION WITH
WHICH THE APPLICANT DOES BUSINESS.
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.
Edith Janec / Rocio Flores

9286666696
CHECKING ACCOUNT(S) NO. __________________________________
IN THE NAME(S) OF_____________________________________
SAVINGS ACCOUNT(S) NO. ____________________________________IN THE NAME(S) OF_____________________________________
_________________________________________________________________________________________________________________
SIGNATURE(S) OF APPLICANT(S)
DATE
11901 Dyer St

Sylmar, CA. 91342
_________________________________________________________________________________________________________________
ADDRESS
II.
CITY/STATE/ZIP CODE
FACILITY NAME
TO BE COMPLETED BY LICENSING AGENCY
(a) TO: (NAME AND ADDRESS OF BANK OR FINANCIAL INSTITUTION)
(b) FROM: DEPARTMENT OF SOCIAL SERVICES

(NAME AND ADDRESS OF LICENSING AGENCY)
RE: FACILITY FILE NO.:

FACILITY NAME:
III. TO BE COMPLETED BY BANK OR FINANCIAL INSTITUTION

THE APPLICANT(S) ABOVE HAS MADE APPLICATION WITH THIS DEPARTMENT FOR LICENSE TO OPERATE A COMMUNITY CARE FACILITY, CHILD
CARE FACILITY, OR RESIDENTIAL CARE FACILITY FOR THE ELDERLY. THEY HAVE INFORMED US THAT YOU MAY RELEASE THE FOLLOWING
INFORMATION TO THIS AGENCY: (ACTUAL DOLLAR AMOUNT - NO CODES)
ACCOUNT INFORMATION AND STATUS:
PERSONAL
DOES APPLICANT HAVE ANY OUTSTANDING LOANS?
Yes
No
TYPE OF LOAN
(If Yes, complete below) CHECKING
MONTHLY PRESENT ACCOUNT NUMBER(S)

PAYMENT BALANCE
SECUREDLOAN NUMBER
DATE LOAN
OPENED
DATE OF FIRST
LOAN PAYMENT
UNSECUREDLOAN NUMBER
DATE LOAN
OPENED
DATE OF FIRST
LOAN PAYMENT
APPLICANTS PAYMENT HISTORY

FAVORABLE
UNFAVORABLE (Explain in
Remarks Section below)
Yes
BUSINESS
CURRENT STATUS OF ACCOUNTS

Yes No LINE OF CREDIT
No
Yes
No SAVINGS
ACCOUNT NUMBER(S)
ACCOUNT NUMBER(S)
DATE ACCOUNT OPENED
DATE ACCOUNT OPENED
DATE ACCOUNT OPENED
PRESENT BALANCE
PRESENT BALANCE
CREDIT LIMIT
AVERAGE MONTHLY BALANCE
AVERAGE MONTHLY BALANCE
AVAILABLE BALANCE
Is account other than individual

e.g., joint or trust? (If Yes, explain
in Remarks Section below)
Is account other than individual

e.g., joint or trust? (If Yes, explain
in Remarks Section below)
MINIMUM PAYMENT
$
Yes
No
Yes
No
AS OF (DATE)
Any restrictions on this line of credit if

so, explain below
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:
SIGNATURE OF OFFICIAL OF BANK OR FINANCIAL INSTITUTION
TITLE
TELEPHONE NUMBER
RETURN DIRECTLY TO LICENSING AGENCY INDICATED IN SECTION II ABOVE.
DATE
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
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
Child Care Center
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
LIC 500 (11/03) (PUBLIC)
640
SPECIFY
DAYS
FROM
TO
4/2007 1/2010
T, TH
SPECIFY
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.
Signature ________________________________________________________________________________ Date __________________
NAME
DATE
EMPL'D
JOB TITLE
SPECIFY
DAYS
FROM
TO
SPECIFY
DAYS
FROM
TO
SPECIFY
DAYS
FROM
TO
Page 2 of 2
DATE
PERSONNEL RECORD
5/10/16
(Form to be completed by employee)
NAME OF FACILITY

FACILITY ADDRESS
11901 Dyer Street Sylmar, Ca.91342

FACILITY FILE NUMBER
Pending
1.
NAME (LAST
FIRST
Flores
PERSONAL
TELEPHONE
MIDDLE)
Rocio
Carolina
(818 ) 972-2314
ADDRESS
ARE YOU 18 YEARS OF AGE OR OLDER?

YES
NO
IF NO, PLEASE STATE YOUR AGE
9035 Noble Avenue Mission Hills, Ca. 91345

SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)
411
98
3890
HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME?
DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?
B4578392
_____________________________
DATE OF LAST PHYSICAL EXAMINATION
1/11/16
YES
YES
DATE OF LAST TB TEST
1/13/16
NO
IF YES, PLEASE LIST ALL NAMES USED.
NO
HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?
CDL NUMBER
NEAREST LIVING RELATIVE NAME:
IF YES, PLEASE EXPLAIN ON BACK OF FORM.

TELEPHONE NUMBER
Carolina Flores
(818) 434-8901
YES
NO
RELATIONSHIP
Mother
ADDRESS
14563 Index Avenue Granada Hills Ca.91344

2.
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
Child Care Resource Center
(818)717-1000
Center Director/Teacher
Business Owner 1/2010
Current
Kinder Care- Knowledge Learning Center
(818)368-8442
Pre-K Teacher
Professional
4/2007
1/2010
ABC Little School
(818)766-5557
Kindergarten Teacher
Professional
2/2004
04/2007
West Valley YMCA
(818)774-2840
Assistant Director/Counselor Budget Cuts
5/1999
2/2004
4.
CIRCLE HIGHEST YEAR COMPLETED
10
11
12
EDUCATION
DIPLOMA
CURRENTLY ENROLLED IN HIGH SCHOOL COMPLETION COURSE?
High School
NO
YES IF YES, GIVE EXPECTED COMPLETION DATE___________________
EMPLOYMENT RELATED EDUCATION COURSES

NAME OF SCHOOL OR ORGANIZATION
COURSE TITLE
AND ADDRESS
LIC 501 (3/99)
(OVER)
NUMBER
CURRENTLY
DATE
UNITS
COMPLETED COMPLETED ENROLLED
4.
EDUCATION (Continued)
NAME UNIVERSITY, COLLEGE OR BUSINESS SCHOOL

AND ADDRESS
MAJOR
SUBJECT
California State University Northridge
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
Mission Hills, Ca.
(818)638-8390
Co-worker/Lead Teacher
Marcy Robles
Granada Hills, Ca.
(818)772-3329
Supervisor/Center Director
Maricela Gonzalez
Sherman Oaks, Ca.
(818)787-0230
Co-Teacher/TA
6.
PROFESSIONAL AND TECHNICAL QUALIFICATIONS
A. List Licenses or Certificates of Competence held:
Child Development Site Supervisor Permit
B. Names of Professional Associations of which you are a member:
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

HEALTH SCREENING REPORT - FACILITY PERSONNEL

All personnel, including applicant, licensee or employed staff of
Residential Care Facilities for the Elderly, Community Care or Child
Care Facilities must demonstrate that their health condition allows them
to perform the type of work required. This health appraisal is to be
completed by or under the direction of a physician.
A health screening, by or under the direction of a physician must
have been performed not more than one year prior to employment
or within seven (7) days after employment.
FACILITY NAME

FACILITY ADDRESS
11901 Dyer Street Sylmar Ca. 91342
PERSON'S NAME
AGE
Rocio Flores
38
POSITION TITLE
TYPE OF FACILITY
Center Director
WORK DAYS PER WEEK
Preschool
WORK HOURS PER DAY
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) ______________________________________________________________________________________________
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT.
ADDRESS
SIGNATURE OF APPLICANT/LICENSEE OR EMPLOYEE
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.
EVALUATION OF GENERAL HEALTH
Patient is is a healthy condition overall. Please view physical report by Doctor
EVALUATION OF ABILITY TO PERFORM WORK DESCRIBED IN THE ABOVE DUTY STATEMENT
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
DATE OF T.B. TEST
1/13/15
DATE OF HEALTH SCREENING
POSITIVE
ACTION TAKEN (IF POSITIVE)
NEGATIVE
NAME OF PHYSICIAN (PHYSICIANS STAMP)
DATE
Kaiser Woodland Hills, Ca.
HEALTH SCREENING BY: (ORIGINAL SIGNATURE)
TELEPHONE #
DATE
1/11/15
(818)719-2000
1/13/15
Please View Doctor's Report

CRIMINAL RECORD STATEMENT

Long-Term Care Ombudsman Program
Persons submitting an application to participate in the Long-Term Care Ombudsman Program must be fingerprinted and
disclose any conviction(s). A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The
fingerprints will be used to obtain a copy of any criminal history you may have.
Have you ever been convicted of a crime in California? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.
It happened a long time ago;

It was only a misdemeanor;
You didnt have to go to court (your attorney went for you);
You had no jail time or the sentence was only a fine or probation;
You received a certificate of rehabilitation;
The conviction was later dismissed, set aside or the sentence was suspended.
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
9035 Noble Avenue
Mission Hills, Ca.
SOCIAL SECURITY NUMBER

(SEE PRIVACY STATEMENT ON REVERSE SIDE)
DATE OF BIRTH
DMV LICENSE NUMBER
411-98-3890
SIGNATURE
05/05/1979
ZIP
91345
B4578392
DATE
05/10/2016
LIC 508B (3/11) REQUIRED FORM - NO CHANGE PERMITTED
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.)
What was the offense?
In which state and city did you commit the offense?
When did this occur?
Tell us what happened. (Use additional sheets of paper if needed)
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.
EMERGENCY DISASTER PLAN FOR

CHILD CARE CENTERS
NAME OF FACILITY
ADMINISTRATOR OF FACILITY
Early Learning Billingual Academy

FACILITY ADDRESS
(NUMBER,
Rocio Flores
STREET,
CITY,
11901 Dyer Street
I.
STATE,
Sylmar
Ca.
ZIP CODE)
91342
TELEPHONE NUMBER
( 818 ) 972-6662
ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)

TITLE
ASSIGNMENT
NAME(S) OF STAFF
1. Rocio Flores
Center Director
DIRECT EVACUATION AND PERSON COUNT
2. Cecilia Dunn
Teacher
HANDLE FIRST AID
3. Edith Janec
Teacher
TELEPHONE EMERGENCY NUMBERS
Teacher
TRANSPORTATION
4.
Delmy Escobar
5. All on site staff
OfficeClerk/Housekeeper/Cook OTHER (DESCRIBE)
6.
II.
EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)
POLICE OR SHERIFF
OFFICE OF EMERGENCY SERVICES
RED CROSS
POISON CONTROL
Foothill Police Department (818) 756-8861

(818)593-3500
911 or Station 91 (818)756-8691

American Association of Poison Control Center (800) 222-1222
OTHER AGENCY/PERSON
HOSPITAL(S)
Olive View- UCLA Medical Center (818) 364-1555
Residency Program Phone Number (818)364-3205
CHILD PROTECTIVE SERVICES
Child Protection Hotline (800) 540-4000
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
Saint Mary's Catholic School

NAME
( 818 ) 459-2378
(
V.
UTILITY SHUTOFF LOCATIONS (INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
ELECTRICITY
Inside of classroom on back wall

WATER
Outside of building behind next to the storage shed

GAS
Automatic Gas Shut Off- outside behind the building
VI. FIRST AID KIT (LOCATION)
Inside of each classroom including the office room and outside inside of the storage shed.
VII. EQUIPMENT
SMOKE DETECTOR LOCATION (IF REQUIRED)
(1)Inside of each classroom

FIRE EXTINGUISHER LOCATION (IF REQUIRED)
(1) Inside of each classroom

TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
All surrounding, by pull station box

LOCATION OF DEVICE
See evacuation map- Inside classroom back wall

VIII. AFFIRMATION STATEMENT
AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS
INDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR
HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.
SIGNATURE
LIC 610 (10/03) (PUBLIC)
DATE
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
LOCAL FIRE INSPECTION AUTHORITY INFORMATION

REQUIRED BY THE DEPARTMENT OF
SOCIAL SERVICES, COMMUNITY CARE LICENSING
DIVISION

DATE:
5/10/16
APPLICANT NAME:
Rocio Flores
FACILITY NAME:
Early Learning Billingual Academy

FACILITY ADDRESS:
11901 Dyer Street Sylmar, Ca. 91342
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:
Los Angeles Fire Department Station 91 (818)756-8691

ADDRESS:
14430 Polk Street

CITY AND ZIP CODE:
Sylmar, Ca. 91342
PLEASE RETURN THIS FORM WITH YOUR COMPLETED APPLICATION

LIC 9054 (3/99)
EARTHQUAKE PREPAREDNESS CHECKLIST (EPC) *

Health & Safety Code 1596.867 requires an Earthquake Preparedness Checklist be included as an attachment to the
Emergency Disaster Plan (LIC 610, LIC 610A and 610A (SP)) and be made accessible to the public. This form is intended
to meet this requirement.
A.
ELIMINATE POTENTIAL HAZARDS IN CLASSROOMS AND THROUGHOUT THE SITE:
Bolt bookcases in high-traffic areas securely to wall studs.
Assess and determine possible escape routes.
Move heavy books and items from high to low shelves.
Secure and latch filling cabinets.
Enlist parent and community resource assistance in

securing emergency supplies or safeguarding the child
care site.
Store a 3-day supply of nonperishable food (including

juice, canned food items, snacks, and infant formula).
Store a 3-day supply of water and juice.
Store food and water in an accessible location, such as

portable plastic storage containers.
Store other emergency supplies such as flashlights, a radio

with extra batteries, heavy gloves, trash bags, and tools.
Maintain a complete, up-to-date listing of children,

emergency numbers, and contact people for each classroom stored with emergency supplies.
Secure cabinets in high traffic areas with child safety latches.
Secure aquariums, computers, typewriters, TV/VCR

equipment to surfaces (e.g., by using Velcro tabs).
Make provisions for securing rolling portable items such as

TV/VCRs, pianos and refrigerators.
Move childrens activities and play areas away from

windows, or protect windows with blinds or adhesive plastic
sheeting.
Secure water heater to wall using plumbers tape.
B.
ESTABLISH A COORDINATED RESPONSE PLAN INVOLVING ALL OF THE FOLLOWING:
CHILDREN:
PARENTS:
Teach children about earthquakes and what to do (see
Post, or make available to parents, copies of the school
resource list below).
Practice duck, cover, and hold earthquake drills under

tables or desks no less than 4 times a year.
C.
earthquake safety plan (including procedures for reuniting

parents or alternate guardians with children, location of
planned evacuation site and method for leaving messages
and communicating).
CHILD CARE PERSONNEL AND LOCAL EMERGENCY AGENCIES:
Identify and assign individual responsibilities for staff following an earthquake (including accounting for and evacuating children,
injury control and damage assessment).
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.
* For more free resources contact:

(1)
Federal Emergency Management Agency (FEMA)
(2)
Office of Emergency Services (OES)
(3)
Red Cross
LIC 9148 (9/00)

FACILITY SKETCH (Floor Plan)

Applicants are required to provide a sketch of the floor plan of the home or facility and outside yard. The floor sketch must label rooms
such as the kitchen, bath, living room, etc. Circle the names of the rooms that will be used by staff/residents/clients/children. Door and
window exits from the rooms must be shown in case of an emergency (see Emergency Disaster Plan). Show room sizes (e.g. 8.5 x
12). Keep close to scale. Use the space below. See back for yard sketch.
FACILITY NAME:
LIC 999 (3/99)
ADDRESS:

FACILITY SKETCH (Yard)

The yard sketch should show all buildings in the yard including the home (with no detail), garage and storage building.
Include walks, driveways, play area, fences, gates. Show any potential hazardous area such as pools, garbage storage,
animal pens, etc. Show the overall yard size. Try to keep the sizes close to scale. Use the space below.
FACILITY NAME:
ADDRESS:

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

APPLICATION FOR A CHILD CARE CENTER LICENSE

FOR DEPARTMENT USE ONLY

REQUESTED ACTION (CHECK ONE):

D. CHANGE OF FACILITY TYPE

COMBINATION CENTER, ETC.)

OTHER PUBLIC AGENCY

NON PROFIT CORP.

LIMITED LIABILITY COMPANY

EMAIL (NOT REQUIRED)

PERSON IN CHARGE OF FACILITY

INFANT CARE CENTER

CHECK HERE FOR TODDLER OPTION

(CHECK APPROPRIATE BOXES FOR COMBINATION

CHILDREN, CHECK HERE:

NUMBER OF NON-AMBULATORY ___________

12. DAYS AND HOURS OF OPERATION:

OTHER (SPECIFY) __________________________________________________________________________________

LICENSING AGENCY NAME:

DATE CONSTRUCTION TO BEGIN: _____________________________________________

SOURCE OF WATER FOR HUMAN CONSUMPTION

IS MAJOR CONSTRUCTION REQUIRED?

WAS FACILITY PREVIOUSLY LICENSED? IF YES, FACILITY NAME AND NUMBER:

IF RENTING OR LEASING, NAME, ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,:

CHILD CARE CENTER FOR MILDLY ILL CHILDREN

11. IF PROVIDING CARE TO NON-AMBULATORY

ALTERNATIVE PUBLIC TELEPHONE

CHILD CARE CENTER (PRE-SCHOOL)

CHECK HERE FOR TODDLER OPTION

Early Learning Bilingual Academy

COUNTY WHERE SIGNED ______________________________

COUNTY WHERE SIGNED ______________________________

LIC 200A (6/08)

INSTRUCTIONS FOR APPLICATION FOR A CHILD CARE CENTER LICENSE

Type or print clearly. Prepare application in duplicate. Return original.

Requested Action: Check appropriate box.

Application Filed by: Check appropriate box.

Property Ownership: Check the appropriate box.

Is Facility to be Constructed or Require Major Building Change? Self-explanatory.

Acknowledgement of right to appeal.

LIC 200A (6/08)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

SOCIAL SECURITY NUMBER

DRIVERS LICENSE NUMBER

ARE YOU 18 YEARS OR OLDER?

California, Los Angeles

11901 Dyer Street Sylmar, Ca. 91342

NAME AND LOCATION OF HIGH SCHOOL

California State University Northridge

Misssion Hills, Ca.

Sherman Oaks, Ca.

PRIOR LICENSURE STATUS

IF YES,, COMPLETE C AND D BELOW.

IF YES, COMPLETE C AND D BELOW:

WERE ANY DISCIPLINARY ACTIONS TAKEN?

HAVE YOU OWNED OR OPERATED ANY BUSINESS?

IF YES, PLEASE EXPLAIN:

DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE?

ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION?

LIC 215 (7/04) (PERSONAL)

IF YES, COMPLETE THE FOLLOWING: