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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543903378
Report Date: 07/25/2022
Date Signed: 10/18/2022 11:31:24 AM


Document Has Been Signed on 10/18/2022 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:LUNA, MARIA FAMILY CHILD CAREFACILITY NUMBER:
543903378
ADMINISTRATOR:LUNA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 359-5215
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:14CENSUS: 8DATE:
07/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria LunaTIME COMPLETED:
11:25 AM
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On 7/25/2022, Licensing Program Analyst (LPA) Ocegueda conducted a case management inspection and met with licensee Maria Luna. LPA Ocegueda toured the facility and took a census.

The purpose of the inspection was to review required documents licensee needs to submit to the Department for a prospective assistant (prospective assistant #1) to be associated to her facility. Licensee and prospective assistant have sent in inaccurate forms and incomplete forms to the Department on two occasions. Today, LPA Ocegueda reviewed the required forms that licensee needs to re-submit (Trustline to Community Care Licensing Criminal Background Clearance Transfer Request – TLR 3 and Criminal Record Statement LIC 508). Prospective assistant has submitted these forms along with a copy of her California Drivers License, however were incomplete and not filled out correctly. Licensee is in urgent need of a qualified assistant to help care for the children while she has outside appointments.

Today, LPA Ocegueda printed the required forms (TRL 3 and LIC 508) and reviewed all forms that are required to have in assistant files including proof of required immunization's, licensing forms and proof of required training's (CPR/First Aid and Mandated Reporter Training). Licensee understands that no adults should assist her in providing care and supervision until they have their required Department clearance.

Licensee will complete these forms with prospective assistant and contact LPA Ocegueda when they are complete in order to the submit to the Department as soon as possible.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

NOTE: This case management report was completed originally on 7/25/2022 at this facility, however written under a different facility profile in error. The report is the exact report provided and signed by this licensee Maria Luna. A signature was obtained on 7/25/2022. The original report was copy and pasted to this correct facility.

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Ruby OceguedaTELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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