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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 02/03/2022
Date Signed: 02/03/2022 12:55:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PEREZ, EMILIO FCCHFACILITY NUMBER:
493009773
ADMINISTRATOR:EMILIO PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 230-1631
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:14CENSUS: 10DATE:
02/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria MedinaTIME COMPLETED:
01:15 PM
NARRATIVE
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LPA Strother made an unannounced inspection to the facility, meeting with assistant Maria Medina, Staff 1 (S1). S1 and Staff 2 (S2) were supervising 10 children, operating within the licensed capacity and ratio requirements. LPA requested a current roster of the children in care. S1 provided LPA with a 4 page roster. LPA reviewed the roster requesting S1 to point out the names of the 10 children in care. S1 stated that 3 of the children, Child 1 - Child 3 (C1-C3) were not listed on the roster. S1 provided LPA with the names and birth dates of C1-C3.

During a tour of the backyard, LPA observed a metal framed gazebo that had one bent leg post. LPA observed and photographed the top corner of the gazebo to be rusted with pieces becoming disconnected, making it potentially unstable and hazardous to the children in care. LPA provided Technical Assistance on the matter, stating that the gazebo should be removed or if possible, repaired before children use the backyard.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC809-D Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative, Maria Medina.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PEREZ, EMILIO FCCH
FACILITY NUMBER: 493009773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2022
Section Cited

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102417 Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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This requirement was not met as evidenced by: the roster provided to LPA was not current. Based on record review and interview of S1, C1-C3 were in care and not listed form LIC9040, which poses a potenial health and safety risk or personal rights risk to the 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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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