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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573615888
Report Date: 02/22/2024
Date Signed: 02/22/2024 05:22:09 PM


Document Has Been Signed on 02/22/2024 05:22 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PALAFOX, EVAFACILITY NUMBER:
573615888
ADMINISTRATOR:PALAFOX, EVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 321-9690
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY:14CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Eva PalafoxTIME COMPLETED:
05:45 PM
NARRATIVE
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Eva Palafox is Spanish speaking. Licensing Program Analyst (LPA) Corina Beckby spoke with Licensee in Spanish, and translated the conversation to English below.

On 2/22/24, Licensing Program Analyst (LPA) met with Licensee, Eva Palafox for a case management and learned that between December 2023 and February 20,2024 an individual who does not have criminal background clearance nor facility association, has been providing care and supervision of daycare children, and at least on one occasion has been left alone with daycare children.

LPA informed Licensee, Eva Palafox, that this report dated 02/22/24, documents a Type A citation that is an immediate Health and Safety, or Personal Rights risk to persons in care. An 809D is issued for the deficiency.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with Licensee, Eva Palafox. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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 02/22/2024 05:22 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: PALAFOX, EVA
FACILITY NUMBER: 573615888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2024
Section Cited
CCR
102370(d)(1)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
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Licensee will provide LPA, assistants identification information to verify if she is criminal background checked and associated with another provider by due date. If so, assistant will provide a transfer request form to be associated with Licennsee as well.
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Based on interview, the licensee did not comply with the section cited above in which assistant does not have criminal background clearance nor is associated to the facility, which poses an immediate health, safety or personal rights risk to persons 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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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