393619809-2-20-2025-53-CC-KGUA-DE4V4F-20250221150614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 393619809
Report Date: 01/02/2025
Date Signed: 02/20/2025 09:47:34 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2024 and conducted by Evaluator Carla Polanco Rivera

PUBLIC

COMPLAINT CONTROL NUMBER: 53-CC-20241230085156

FACILITY NAME:	HERNANDEZ, ELVIA & ANTONIO		FACILITY NUMBER:	393619809
ADMINISTRATOR:	HERNANDEZ, ELVIA & ANTONIO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 426-6244
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	14	CENSUS: 3	DATE:	01/02/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Licensee Elvia Hernandez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Co-Licensee Antonio is not present during daycare hours.

INVESTIGATION FINDINGS:

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This is an amended version of a report, originally created on 1/2/25.

Licensing Program Analyst Carla Polanco met with Licensee Elvia Hernandez to follow up on the above complaint allegation. It was alleged that Licensee's spouse and co-licensee, Antonio Hernandez is currently out of the country and not present during daycare hours. During today's visit the facility was toured. Present were 3 children being supervised by Licensee.

Per LPA interview with the provider, her spouse and co-licensee is absent from her childcare facility at this time due to an emergency. LPA informed Licensee, that this report documents a Type B citation, which is a Potential Health and Safety, or Personal Rights risk to persons in care. A separate 809-D page was issued for the deficiency. An exit interview was conducted, and the report was reviewed with Licensee. LPA Polanco posted a notice of site visit. Licensee understands the notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 53-CC-20241230085156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA & ANTONIO	FACILITY NUMBER: 393619809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/03/2025 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	The licensee shall be present in the home ...... children in care are supervised at all times. When... temporarily absent from the home... his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement was not met by evidenced by:	1 2 3 4 5 6 7	Licensee requested that her husband Antonio Hernandez be removed from the License effective today 1/2/25.
	8 9 10 11 12 13 14	Upon interview with Licensee, it was revealed that co-Licensee has not been present in the daycare home since December 10, 2024.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC9099 (FAS) - (06/04)

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