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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:41:26 PM


Document Has Been Signed on 04/27/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CLARK, GUADALUPE & JUDSONFACILITY NUMBER:
070209044
ADMINISTRATOR:CLARK, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 937-6152
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:12CENSUS: 7DATE:
04/27/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Guadalupe ClarkTIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/27/22 at 2:30 pm Licensing Program Analysts (LPAs) Monica Mathur and Christina Watts conducted an unannounced Plan Of Correction inspection and met with Licensee, Guadalupe Clark (also known as Lupita). Purpose of the inspection is to conduct Plan of Correction visit, and clear citations from annual inspection of 4/14/22.

Off limit area (Third Bedroom) is now approved to be used for naps and citation is cleared today. All adults present in the home today are fingerprint cleared. Citation for Criminal Record Clearance is cleared today. Letters of Clearance were provided.

Present in the home during inspection were 7 children (5 infants, 2 preschool age), Licensee (Guadalupe) and Helper (Teresa Ramirez). Co-licensee Judson Clark was not present in the home. Licensee's son Patrick Clark arrived later and was present during exit interview. Facility is out of ratio today with an extra infant in care. Type A Citation issued on 809-D page. Infants are children under 2 years old.

LPA Monica Mathur informed Licensee, Guadalupe that this report dated 4/27/22 with 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Mathur informed the Licensee to provide a copy of this licensing report dated 4/27/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification



Exit interview conducted and report was reviewed with the Licensee, Guadalupe Clark and Patrick Clark. A notice of site visit was given and must remain posted for 30 days
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2022
Section Cited

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102416.5 Staffing Ratio & Capacity (d) for a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:(1) Twelve children, no more than four of whom may be infants. This requirement is not met as evidenced by:
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Per LPA's inspection, present in the home today are 5 infants and 2 preschool age with Licensee and Helper. Licensee is out of ratio by 1 extra infant. This poses an immediate risk to health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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