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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115406098
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:39:05 PM


Document Has Been Signed on 06/30/2022 02:39 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:ULLOA, GRACIELA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115406098
ADMINISTRATOR:ULLOA, GRACIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 865-2195
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY:14CENSUS: 8DATE:
06/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Graciela UlloaTIME COMPLETED:
02:45 PM
NARRATIVE
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A visit was conducted in response to an unusual incident that was self-reported in a timely manner by Graciela Ulloa, the licensee. The incident occurred on 6/22/22 at about 2:30pm. Community Care Licensing Division (CCLD) was notified within 24 hours and unusual incident report was sent in writing within the 7 days as required. Licensee reported that a child (C1) had gone through the garage door that was cracked open and took of running.

LPA Mendez conducted interview with licensee who stated that as she was escorting the children to the backyard, the children go through the garage door to go through the backdoor to play outside in the backyard. The garage opening door was cracked open, licensee stated that she had the children in the backyard patio and saw how C1 took off and ran from the garage door open. She stated that she went after the child who took off running down the street. Licensee stated that she had returned back to the house to get her car so that she could retrieve C1. Licensee had lost visual of child for about 5 minutes, she lost visual when she had returned to her home to retrieve her car. Licensee stated that a woman on the from around the corner of her house had the child and had called the police. Licensee stated that the police had arrived when the woman called the police and the police had arrived and verified with licensee that C1 was enrolled in care.

Licensee stated that she had informed parent right away when the incident occurred.

LPA Mendez faxed Orland Police Department for report.

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ULLOA, GRACIELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406098
VISIT DATE: 06/30/2022
NARRATIVE
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Absence of supervision resulting in a child wandering away from the childcare. The following violation of the California Code of Regulations, Tittle 22: Division 12 was observed: see LIC 809D. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled should sign LIC 9227 form and to parents/guardians of children newly enrolled at the facility during the next 12 months. Notice of Site Visit shall be posted for 30 days from today’s visit.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2022 02:39 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: ULLOA, GRACIELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited

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Absence of Supervision 1597.58(c)(2) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, for any of the following serious violations: Absence of supervision, including, but not limited to, a child left unattended, and supervision of a child by a person under 18 years of age.
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This requirement was not met as evidenced by interviews the child was unsupervised on 6/22/22
An immediate civil penalty of $500 applies. This poses an immediate health and safety risk to children in care.
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Recommended resource for Active Supervision training: https://eclkc.ohs.acf.hhs.gov/safety-practices/article/keep-children-safe-using-active-supervision

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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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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