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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103908972
Report Date: 06/26/2019
Date Signed: 06/26/2019 01:00:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:PELAGIO, XOCHITL FAMILY CHILD CAREFACILITY NUMBER:
103908972
ADMINISTRATOR:PELAGIO, XOCHITLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 210-2174
CITY:HURONSTATE: CAZIP CODE:
93234
CAPACITY:14CENSUS: 6DATE:
06/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Xochitl PelagioTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Robert Gutierrez conducted an unannounced annual inspection. LPA met with Licensee Xochitl Pelagio. LPA conducted a tour of the home, inside and outside, as shown on the facility sketches (LIC 999A) provided. The rooms accessible to children in care are the living room, dining room, kitchen, day care room, hallway bathroom and front yard. Off-limits bedrooms #1 and #2 are not being made inaccessible. Master bedroom is inaccessible to children in care via a plastic door knob spinner. Three dogs were observed during today’s inspection; licensee is aware of the safety of children around animals. Licensee stated her dogs are kept inaccessible from children and placed in the off-limits back yard. There are no "bodies of water" or firearms in this home. No poisons were observed on the premises. Cleaning compounds, medications and other hazardous items are inaccessible to children. Kitchen and restroom cabinets and drawers have functional plastic latches and locks making items inside inaccessible to children in care. There is no fireplace. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. There is a working telephone (559) 210-2174 and number was verified. Adequate supervision is being provided during this inspection. Licensee stated when children play in the front yard the fence is closed and she remains outside with children. Capacity as specified on the license is being maintained. Licensee does not have a current roster of the children. Speaking with the licensee she stated, four children were missing from the roster. Licensee does not have any paperwork for child #1, #2 or #3 on file. Licensee maintains documentation of immunizations for pertussis, measles and influenza for herself. Fire drills are conducted and documented with the date and time every six months. Licensee is aware that children are never to be left in parked vehicles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care. Pediatric CPR/First Aid is current and expires 08/11/2020. Licensee has not completed her Mandated reporter training. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. Postings such as Emergency Disaster Plan, Earthquake preparedness checklist, facility license and notification of parents rights poster are posted on the living room wall. Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address. Days and hours of operation are Monday – Friday; 5:00 AM – 5:00 PM.

Continued on 809-C

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Robert GutierrezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2019
Section Cited
CCR
1596.8662(c)
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Current proof of completion for each licensed child care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department. This requirement is not met as evidenced by a interview conducted during today’s inspection.
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License stated she shall take this training and send a certificate to the Community Care Licensing (CCL) office located in Fresno. This correction shall be submitted by the given due date.
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Upon inspection, licensee stated she has not completed her mandated reporter training. This poses as a potential risk to the health, safety, or personal rights of children in care.
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Type B
07/03/2019
Section Cited
CCR
102417(g)
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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. This requirement is not met as evidenced by observation conducted during today's inspection.
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Licensee agreed to make both of these bedrooms inaccessible to children by installing plastic door knob or other preventative entry device on the door. Licensee shall send proof of the correction to the CCL office by the given due date.
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Upon inspection LPA observed bedroom #1 and #2 without a preventative entry device on the door. This poses as a potential risk to the health, safety, or personal rights 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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Robert GutierrezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2019
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement is not met as evidenced by speaking with the licensee during today’s inspection.
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Licensee stated she shall send a current roster of children in care to Community Care Licensing (CCL) office by the given due date.
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Licensee stated she has four children missing from her roster. This poses as a potential risk to the health, safety, or personal rights of children in care.
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Type B
07/03/2019
Section Cited
CCR
102421(a)
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Child's Records. The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by speaking with the licensee during today’s inspection.
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Licensee stated she shall submit copies of completed and signed paperwork for children #1, #2 and #3 to the CCL office. Proof of this correction shall be submitted by the given due date.
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Licensee stated she did not have any signed paperwork for Child #1, #2 or #3 This poses as a potential risk to the health, safety or personal rights 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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Robert GutierrezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972
VISIT DATE: 06/26/2019
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are found


(see next page): 809 D
Licensee was provided a copy of appeal rights.

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Robert GutierrezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4