<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623873
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:24:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:14CENSUS: 4DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Melina Jimenez TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
During today's case-management, Licensing Program Analysts (LPAs) Fabiola Diaz and Arianna Manabat inspected the inside and outside of the facility. Inspection began around 9:15 am.

On today's date licensee updated her off-limits areas to be: upstairs master bedroom, entire bottom floor, left side of backyard (outside of fenced play yard). On today's date, LPAs observed the outside play space to have a fenced pond containing water. The pond is surrounded by a wooden fence, which is locked with a padlock. Licensee explained that the pond fills up during winter with the water from the rain. Licensee stated that children don't play inside the pond area. On today's date, LPAs observed the fence around the pond to not meet Title 22 regulations. Some areas of the fencing were less than 5 feet tall, and the fence is climbable.

Title 22 deficiency are cited on the subsequent page of this report. Appeal Rights were provided, and an exit interview was conducted. A Notice of Site Visit was posted and must remain posted for 30 days.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: JIMENEZ, MELINA
FACILITY NUMBER: 343623873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2022
Section Cited

1
2
3
4
5
6
7
102417 Operation...(5)...ensure the inaccessibility of pools...spas, fish ponds and similar bodies of water through... (A) Fences shall be at least five feet high...fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee did not ensure the pond to be surrounded with a fence at least 5 feet tall and that the fence meets Title 22 regulations.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2