503909242-3-15-2024-04-CC-VMIS-D3DSDB-20240315134651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 503909242
Report Date: 03/16/2022
Date Signed: 03/15/2024 01:46:51 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2022 and conducted by Evaluator Stefanie Galvan

PUBLIC

COMPLAINT CONTROL NUMBER: 04-CC-20220307150901

FACILITY NAME:	BELERIQUE, NANCY FAMILY CHILD CARE		FACILITY NUMBER:	503909242
ADMINISTRATOR:	BELERIQUE, NANCY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 480-7370
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	14	CENSUS: 9	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee, Nancy Belerique		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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1) Facility did not follow proper COVID-19 mask guidance
2) Child sustained injuries while in care due to lack of supervision

INVESTIGATION FINDINGS:

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This report is an ameneded report. On 03/15/2024, an unannounced complaint visit was conducted by Licensing Program Analyst (LPA) Valerie Mireles. LPA met with Licensee, Nancy Belerique. LPA toured the facility and a census was taken. The purpose of today’s visit was to provide findings for the above allegations. LPA Stefanie Galvan conducted the investigation.

The investigation revealed the following: On 03/16/2022, licensee admitted to LPA Galvan to not wearing masks for a few months. Licensee also admitted that she did not secure a child properly in a high-chair when she turned her back. This caused the child to fall and injure themself. Licensee provided details about the incident/fall that took place which caused injury.
Based upon information and interviews conducted, the preponderance of the evidence standard has been met, therefore the above allegations numbered 1 and 2 are found to be SUBSTANTIATED.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cynthia Brannon	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Valerie Mireles	TELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 04-CC-20220307150901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/16/2022

NARRATIVE

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Exit interview conducted with licensee, Nancy Belerique. A copy of this report and appeal rights were provided. A Notice of Site Visit Form was posted on parent's board and must remain posted for 30 days.

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: Cynthia Brannon	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Valerie Mireles	TELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 04-CC-20220307150901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/16/2022 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	Operation of a Family Child Care Home (a) -The licensee shall be present in the home and shall ensure that children in care are supervised at all times... This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit to licensing office a written document which states she understands CCR 102417(a) and how she will be pro-active about it in the future. Licensee will submit form to licensing office by 3/23/22.
	8 9 10 11 12 13 14	Based on interview and records review, Licensee did not conduct supervision at all times, in that child sustained injury while in care, as described in LIC 9099. This poses an immediate risk to the health, safety, or personal rights of children.	8 9 10 11 12 13 14
Type B 03/16/2022 Section Cited CCR 101223(a)(2)	1 2 3 4 5 6 7	Personal Rights; (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she shall conduct a staff meeting with all staff to review children’s personal rights and shall submit the meeting agenda and signatures of attendees to Community Care Licensing (CCL) by 03/23/2022.
	8 9 10 11 12 13 14	During interview with LPA Galvan, licensee admitted to not wearing masks/face coverings "for a few months now." Mask requirements did not become"recommended" until 3/11/2022. This poses a potential risk to the health, safety, or personal rights of children in care.	8 9 10 11 12 13 14

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 Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Stefanie Galvan	TELEPHONE: (559) 341-5431
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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