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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405094
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:11:06 PM


Document Has Been Signed on 07/25/2023 04:11 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 CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:FIRST CHURCH OF GOD EARLY ENRICHMENT CENTERFACILITY NUMBER:
100405094
ADMINISTRATOR:ANTARAMIAN, LISAFACILITY TYPE:
830
ADDRESS:3920 N. FIRST STREETTELEPHONE:
(559) 227-3222
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:26CENSUS: 12DATE:
07/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Samantha EllsworthTIME COMPLETED:
04:30 PM
NARRATIVE
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On July 25, 2023, LPA A Mendoza and LPM C Brannon conducted a case management inspection. LPA A Mendoza and LPM C Brannon met with Assistant Director Samantha Ellsworth. During today’s inspection, LPA and LPM toured facility inside and outside areas, interviewed staff, reviewed staff and infant files. In classroom #1 there were four infants per one staff member. In classroom #3, the napping room, there were eight napping infants with one staff.

Facility reported on July 19, 2023, infant (I1) was found without adult supervision in infant classroom #2. Interviews reflect that staff #1(S1) left with infants and was not aware that I1 was still in the classroom. S1 took the infants outside to play. Assistant director found I1, alone without the required adult supervision. I1 was standing near the front door, waiting to be let out. Per assistant director, S1, did not follow established protocol of reviewing the number of infants in classroom. Per Title 22, 101429 Responsibility for Providing Care and Supervision for Infants: Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.

During today's inspection, Parent's Rights were reviewed with assistant director. At the time of acceptance of each child in care, the licensee shall inform each child's parent or authorized representative of his/her rights that include, but are not limited to when a child is ill, receives an injury and when a child is left without adult supervision.

LPA A Mendoza and LPM C Brannon informed Assistant Director Samantha Ellsworth that this report dated July 25,2023 document one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of infants in care.

CONTINUED ON FOLLOWING PAGE
SUPERVISOR'S NAME: Cynthia BrannonTELEPHONE: (559) 650-7884
LICENSING EVALUATOR NAME: Aurelio MendozaTELEPHONE: (559) 815-8119
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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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Document Has Been Signed on 07/25/2023 04:11 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 CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: FIRST CHURCH OF GOD EARLY ENRICHMENT CENTER
FACILITY NUMBER: 100405094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
101429(a)(1)

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Responsibility for Providing Care and Supervision for Infants. In addition to Section 101229, the following shall apply: Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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Per assistant director, training and updated protocol of documenting the number of infants in classroom, taken out to other areas and brought back to classroom to ensure infants are not left alone without adult supervision.
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Responsibility for Providing Care and Supervision for Infants. In addition to Section 101229, the following shall apply: Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement was not met as evidenced by interviews and staff reporting the incident. This is an immediate personal rights, health and safety risk to infants in care.
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A detailed agenda and copy of updated protocol will be sent to the Fresno Community Care Licensing office no later than August 1, 2023.

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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: Cynthia BrannonTELEPHONE: (559) 650-7884
LICENSING EVALUATOR NAME: Aurelio MendozaTELEPHONE: (559) 815-8119
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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 CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: FIRST CHURCH OF GOD EARLY ENRICHMENT CENTER
FACILITY NUMBER: 100405094
VISIT DATE: 07/25/2023
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Also, LPA A Mendoza and LPM C Brannon informed the assistant director to provide a copy of this licensing report dated July 25, 2023, that documents any Type A citation to parents/guardians of all infants currently enrolled by the next business day or the next day the infant is 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.

LPA A Mendoza and LPM C Brannon provided a copy of LIC 9224 and Title 22, section 101429 Responsibility for Providing Care and Supervision for Infants during today’s inspection.

Exit interview conducted and report was reviewed with the assistant director. This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Cynthia BrannonTELEPHONE: (559) 650-7884
LICENSING EVALUATOR NAME: Aurelio MendozaTELEPHONE: (559) 815-8119
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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