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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543905296
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:54:46 PM


Document Has Been Signed on 10/21/2022 02:54 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:PLASCENCIA, ANA FAMILY CHILD CAREFACILITY NUMBER:
543905296
ADMINISTRATOR:PLASCENCIA, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 625-0423
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:14CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ana PlascenciaTIME COMPLETED:
03:10 PM
NARRATIVE
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On 10/21/2022, Licensing Program Analyst (LPAs) Theresa Marquez and Daniel Alvarez conducted a Case Management inspection and met with licensee Ana Plascencia.

The purpose of the inspection is due to the $280 outstanding annual fees that are past due.
LPA's reviewed with Plascencia her payment history. Licensee stated she paid her annual fees but could not provide proof of payment. LPA's provided to Plascencia a printout of her facility payment history.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, the following deficiency was cited. See page LIC809-D.

An exit interview was conducted with Ana Plascencia. Licensee was provided a copy of the Facility Evaluation Report (LIC 809), the Appeal Rights and the Notice of Site Visit form.
SUPERVISOR'S NAME: Luisa GavoutianTELEPHONE: (559) 650-7879
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/21/2022 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PLASCENCIA, ANA FAMILY CHILD CARE
FACILITY NUMBER: 543905296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited

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LICENSING FEES - An applicant or licensee shall be charged fees as specified in Health and Safety Code Section 1596.803: This requirement was not met as evidenced by record review. Licensee has not paid her annual
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fees of $208 that were due in March 2022.
This poses a potential risk to the health, safety and personal rights to children in care.
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outstanding annual fees by 11/21/2022.

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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: Luisa GavoutianTELEPHONE: (559) 650-7879
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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