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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622079
Report Date: 01/27/2020
Date Signed: 01/27/2020 03:30:16 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:PERDUE, KRISTIFACILITY NUMBER:
393622079
ADMINISTRATOR:PERDUE, KRISTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 740-0165
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 11DATE:
01/27/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kristi PerdueTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stacey Williams arrived at the home of Licensee, Kristi Perdue for an unrelated inspection. LPA met with Licensee and observed (11) eleven children supervised by Licensee and her daughter. Both have been fingerprint cleared. During today's inspection, Licensee informed LPA that her adult son was in the home and resides in the home on a full time base. Licensee's son is eighteen years old and has not been fingerprint cleared.


Based on today's observations, Title 22 Deficiencies have been cited on the attached LIC 8099D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

This report was reviewed and discussed with Licensee. A notice of site visit and appeal rights were provided.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2020
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: 01/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2020
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance
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 or a criminal record exemption as required by the Department. This requirement was not met as by evidence: LPA was informed by the Licensee that her adult son resides in the home. There is no record of criminal record clearance for the Licensee's son on file. This is a potential immediate risk to the health and safety of children in care.
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civil penalty assessed.

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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: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2020
LIC809 (FAS) - (06/04)
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