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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243902523
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:01:43 PM


Document Has Been Signed on 05/03/2022 03:01 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, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:ORTIZ, JESSICA FAMILY CHILD CAREFACILITY NUMBER:
243902523
ADMINISTRATOR:ORTIZ, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 710-9360
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:14CENSUS: 1DATE:
05/03/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jessica OrtizTIME COMPLETED:
03:15 PM
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On 05/03/2022 Licensing Program Analysts (LPAs) Robert Gutierrez and Rene Mancinas and Licensing Program Manager (LPM) Juvenal Moctezuma, conducted an unannounced case management legal inspection. LPAs and LPM met with Licensee, Jessica Ortiz also present was Staff #1 (S1). The purpose of inspection was to provide Licensee with a notification letter of immediate exclusion for adult son, Gabriel Marcus Ortiz. This letter informs Licensee that Gabriel Marcus Ortiz is excluded from being present in all facilities licensed by the Department. Licensee is to ensure Gabriel Marcus Ortiz to be immediately excluded from having contact with day care children or being physically present at (any) facility. Licensee was advised exclusion order remains in place, unless otherwise notified in writing by the Department. LPAs and LPM provided Licensee with information/rights to appeal Department’s order within 15 days of today’s service notification. Licensee signed a copy of order acknowledging receipt. Licensee was provided with original copy of order. LPAs informed Licensee that if Gabriel Marcus Ortiz were to arrive at the facility, she must immediately contact local law enforcement and inform the Department.

In addition, LPAs provided Licensee with copies of LIC 995B Family Child Care Home Addendum To Notification of Parent’s Rights (Regarding Removal/Exclusion). LPAs and LPM informed Licensee they are to provide LIC 995B form to parents by the end of day, or by the next time day child(ren) are in care. Licensee understands parents are to sign LIC 995B acknowledging receipt of notification, and the form must be stored in each child’s and subject to review/verification by the Department during future inspections.

Per California Code of Regulations Title 22 Division 12 Chapter 3, no deficiency is being cited today. Notice of Site 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: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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