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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500249
Report Date: 05/05/2022
Date Signed: 01/26/2023 03:16:44 PM

Document Has Been Signed on 01/26/2023 03:16 PM - It Cannot Be Edited

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:ESQUIVEL, MARIA OLIVIAFACILITY NUMBER:
394500249
ADMINISTRATOR:ESQUIVEL, MARIA OLIVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 712-9167
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Olivia EsquivelTIME COMPLETED:
12:15 PM
NARRATIVE
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This is an amend version of a report originally signed on 05/05/2022.

The report was amended on 1/26/2023, because the deficiency cited on 5/5/2022 was appealed. The citation was incorrectly cited due to a typing error, and therefore it was dismissed.



On 5/5/2022, Licensing Program Analyst (LPA) Tjhia and Licensing Program manager (LPM) Engelman met with the licensee, Maria Olivia Esquivel, for the case management inspection. Licensing staff toured the facility, observed the care and supervision of the children and reviewed records. LPA and LPM observed an infant was sleeping on adult's bed. The Safe sleep regulation require children under the age of 1 to sleep in a crib or play yard.



This report was reviewed and discussed with licensee. A notice of site visit and appeal rights were provided.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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Document Has Been Signed on 05/10/2022 11:25 AM - It Cannot Be Edited


Created By: Erwin Tjhia On 05/05/2022 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ESQUIVEL, MARIA OLIVIA
FACILITY NUMBER: 394500249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/06/2022
Section Cited

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INFANT SAFE SLEEP

(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.
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This requirement was not met as evidences by "LPA and LPM observe an infant age under one year old sleep on an adult bed". This is an immidiate risk to the health and safety of children in care.
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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