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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622079
Report Date: 06/28/2019
Date Signed: 06/28/2019 10:54:50 AM

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:PERDUE, KRISTIFACILITY NUMBER:
393622079
ADMINISTRATOR:PERDUE, KRISTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 740-0165
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 11DATE:
06/28/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kristi PerdueTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Mary Ponce met with licensee regarding a separate inspection. While inspecting areas of the home that are accessible to children, LPA observed a canister of Gasoline outside on a low table within reach of children which is an immediate risk to the health and safety of the children in care. Licensee stated that children did not have access to the backyard due to work being done. LPA requested licensee to remove the Gasoline from the backyard. Licensee placed the Gasoline in the garage. As of today 6/28/19, licensee is requesting the backyard remain off limits until the yard work is complete. LPA will conduct a follow up inspection when Licensee is ready to place the backyard back on limits.

Title 22 deficiencies are cited on the subsequent pages of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days 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 with the children's forms as a receipt whenever any Type A documents are provided by the licensee (LIC 9224 was provided).

LPA read the report to the licensee. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PERDUE, KRISTI
FACILITY NUMBER: 393622079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2019
Section Cited
CCR
102417(g)(4)
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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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POC: Licensee immediately removed the gasoline and placed it in the garage.
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This regulation was not met as evidence by Gasoline sitting on a low table within reach of children in care. Licensee stated that the children did not have access to the backyard due to yard work
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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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2019
LIC809 (FAS) - (06/04)
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