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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393608056
Report Date: 12/03/2019
Date Signed: 12/03/2019 03:49:16 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:ROSAS, MARIAFACILITY NUMBER:
393608056
ADMINISTRATOR:ROSAS, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 835-8315
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY:14CENSUS: 9DATE:
12/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Maria RosasTIME COMPLETED:
04:15 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
Licensing Program Analyst (LPA) Jeevun Birk-Miller and Licensing Program Manager (LPM) Jeanne Smith met with the Licensee, Maria Rosas to discuss an Unusual Incident Report that was self-reported by the Licensee to the Department on 11/06/19. Investigator Sonia Boyal from the Department's Investigation Branch conducted an investigation with the collaboration of the Tracy Police Department. Based on the interviews gathered during the course of the investigation the incident was found to be substantiated. The following Type A deficiency was cited on the 809-D page of the this report.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 is available on the website. If the LIC 9224 is not used, the licensee shall prepare a statement indicating the documents have been provided. Licensee shall require the parent/guardian to sign and date the statement and shall keep the signed statement as receipt. Verification of receipt shall be kept in each child's file at the facility. An exit interview was conducted and Appeal Rights were provided.

SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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 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: ROSAS, MARIA
FACILITY NUMBER: 393608056
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2019
Section Cited

1
2
3
4
5
6
7
Personal Rights. 102423(a)(1) To be treated with dignity in his/her personal relationship with staff and other persons.




This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews it was determined adult #1 made inappropriate contact with child #1. This poses an immediate health and safety risk to children in care.
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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2