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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100404078
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:15:16 PM


Document Has Been Signed on 02/28/2023 03:15 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:PANDA'S FOWLER PRESCHOOLFACILITY NUMBER:
100404078
ADMINISTRATOR:DIXON-BREWER, LORIEFACILITY TYPE:
850
ADDRESS:231 SOUTH SIXTH STREETTELEPHONE:
(559) 834-1395
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:61CENSUS: 28DATE:
02/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Renee CervantesTIME COMPLETED:
03:35 PM
NARRATIVE
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On 2/28/2023, Licensing Program Analyst (LPA) Ocegueda conducted a case management inspection. The purpose of the case management inspection was to address the complaint investigation process and to review required forms that are required to be available to the Licensing Department upon request. LPA Ocegueda met with Site Supervisor Renee Cervantes, toured the facility and took a census.

During a complaint inspection initiated on 2/8/2023, it was determined that Site Supervisor did not disclose information that was pertinent to the investigation at hand. LPA revealed the nature of the complaint (criminal record clearance) and Site Supervisor only disclosed information for staff #1 and not staff #2. When discussing who worked at the facility, Site Supervisor did not disclose information regarding staff #2 and in addition when providing LPA an updated Personnel Roster (LIC 500) dated 2/8/2023, Site Supervisor did not indicate both staff #1 and staff #2 on the document. Both staff #1 and staff #2 were found to not have required criminal record clearance (see 9099 and 9099 D report dated 2/29/2023) for further details.

LPA reviewed the requirement for staff to disclose all pertinent information when being interviewed and to avoid making false statements, omitting information, or providing false documents/information to any Licensing Department representative as this goes against the regulation requirements. LPA also reviewed Inspection Authority with Site Supervisor today.

In addition, on 2/8/2023, Site Supervisor could not provide a copy of a children’s roster that had all pertinent and required information. Site Supervisor instead provided a list of children with only DOB information. Site Supervisor completed the Children’s Roster and used our Department form LIC 9040 and provided it on a later date via email. In addition, Site Supervisor did not have any past children’s rosters with the required information to assist in the investigation.

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Ruby OceguedaTELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PANDA'S FOWLER PRESCHOOL
FACILITY NUMBER: 100404078
VISIT DATE: 02/28/2023
NARRATIVE
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LPA informed Site Supervisor that children’s records should be kept at the facility for at least three years after any child left the facility. LPA provided the Site Supervisor with a list of required forms that should be available to the Department during any inspection. Site Supervisor Renee confirmed she is responsible for managing forms that are at the facility. Per Site Supervisor, she has recently taken the Record Keeping Orientation.

LPA explained that failure to correct these incidents could warrant future citations, an informal meeting or a non-compliance meeting to ensure the understanding and compliance of these requirements by licensee and all staff.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, the following deficiencies were cited (see LIC 809-D). Appeal Rights were provided.

An exit interview was conducted with Site Supervisor Renee Cervantes today.

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Ruby OceguedaTELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/28/2023 03:15 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: PANDA'S FOWLER PRESCHOOL
FACILITY NUMBER: 100404078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited

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False Claims.No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the child care center or any of the services provided by the center...This requirement was not met as evidenced by: Interview and Record review.
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Site Supervisor stated she would provide training to staff on this requirement and submit proof of the training including a dated agenda with topics reviewed signed by each staff. Proof will be submitted to the Department by POC date 3/14/2023.
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On 2/8/2023, multiple staff provided false information through interview and documentation provided (Personnel Report, LIC500) regarding staff #1 and staff #2. This poses a potential health, safety and or personal rights risk to persons in care.
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Type B
03/14/2023
Section Cited

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Current roster of children provided care in facility required. Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This requirement was not met as evidenced by record review and interview.
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On 2/29/2023, Site Supervisor provided proof that she had completed the online record keeping orientation. Site Supervisor also completed an children's roster which was provided to LPA. Licensee stated after taking the online orientation, she understands the requirement to have a completed children's roster as well as the understanding of how to manage and maintain records. Deficiency cleared today.
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On 2/8/2023, Site Supervisor could not provide the Department with current or past Children's Roster that contained all required information. This posed a potential risk to the health, safety and or personal rights to 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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Ruby OceguedaTELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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