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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503909242
Report Date: 01/23/2020
Date Signed: 01/23/2020 05:02:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:BELERIQUE, NANCY FAMILY CHILD CAREFACILITY NUMBER:
503909242
ADMINISTRATOR:BELERIQUE, NANCYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 480-7370
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:14CENSUS: 11DATE:
01/23/2020
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nancy BeleriqueTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Henley arrived unannounced to conduct an annual required inspection. At the time of arrival at 3:00 p.m., present during the inspection was the licensee, one licensee's biological minor child and 10 day-care children. There was no assistant present. Licensee stated that her assistant just left home for the day. At 3:30 p.m., licensee had another assistant come into the home to assist with supervision of the children and now within her ratio/capacity. LPA toured the home, inside and outside, as shown on the facility sketches provided. The areas that are accessible to children are the living room, kitchen/dining area, and hall bathroom. No pets were observed at today's visit. There are no "bodies of water" or firearms in this home. Cleaning compounds, medications and other hazardous items are inaccessible to children. Fireplace is not in use during day care hours. There is a fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. The home provides safe toys, play equipment, and materials. Swing set in back yard that is anchored to the ground. Licensee conducts and documents fire/disaster drills at least once every six months. Licensee has a current roster of the children. LPA reviewed ten children's files. Licensee is current on the online Child Abuse Mandated Reporter training and immunization.The licensee completed CPR and First Aid and it expires on 9/2021. All adults who reside or work in the home have a criminal record clearance or exemption.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: BELERIQUE, NANCY FAMILY CHILD CARE
FACILITY NUMBER: 503909242
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2020
Section Cited

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102416.5(d) - Staffing Ratio and Capacity:For a Large Family Child Care Home, the maximum number of children for whom care may
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be provided at any one time when there is an assistant provider in the home. This requirement was not met as evidenced by: At time of LPA arrival, licensee was alone supervising 11 children. One 5 month old infant child was observed in a bedroom with the door shut, laying on the floor on his tummy and crying. Children must be supervised and capacity/ratio needs to be maintained at all times. This is an immediate health & safety risk to children in care.
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home to help supervise with the children. The assistant arrived at 3:30 p.m. and licensee was back into the capacity/ratio per Title 22 Regulation. Licensee to send her plan of action/correction to CCL by 1/24/2020.

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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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2020
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: BELERIQUE, NANCY FAMILY CHILD CARE
FACILITY NUMBER: 503909242
VISIT DATE: 01/23/2020
NARRATIVE
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Licensee is advised forms and updated information may be obtained on the CCLD website(www.ccld.ca.gov). Licensee is also advised that it is her responsibility to stay current with regulations.
Hours or operation are Monday through Friday from 7:00 AM to 5:30 PM and as arranged; less than 24 hours.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following is cited (see page 3). Appeal Rights left with licensee.

Site Visit Notice posted on the parent board. Exit interview was conducted.

The licensee shall post and provide copies of this licensing report to parents/guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of this report must be given to each enrolled child's parent(s). The licensee was provided a copy of the "Fact Sheet" for AB 633 (Parent Notification Requirements), along with a copy of the relevant documents this date. The licensee must implement the new procedure immediately, by having all parents of enrolled children sign the Acknowledgement of Receipt of Licensing Reports and must retain a copy in each child's file.




SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: BELERIQUE, NANCY FAMILY CHILD CARE
FACILITY NUMBER: 503909242
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2020
Section Cited

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Immunization: The licensee shall document each child's immunizations as required and shall maintain such documentation for as long as the child is enrolled.
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This requirement was not met as evidenced by: Upon children's file review today, Child #4, #5, #8, #10 were missing immunization records.
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Type B
02/06/2020
Section Cited

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Child Records: The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7). Upon children's file review today, Child #10 was missing a complete licensing file with all the required forms.
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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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4