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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:08:44 PM

Document Has Been Signed on 04/29/2022 04:08 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CLARK, GUADALUPE & JUDSONFACILITY NUMBER:
070209044
ADMINISTRATOR:CLARK, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 937-6152
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
04/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Guadalupe ClarkTIME COMPLETED:
04:30 PM
NARRATIVE
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On 4/29/22 at 2:00 pm Licensing Program Analysts (LPAS) Monica Mathur and Christina Watts conducted an unannounced Plan of Correction inspection and met with Licensee, Guadalupe Clark. LPAs explained the purpose of today's inspection which is to clear citation issued on 4/27/22 for being out of ratio compliance.

Present today with Licensee and Helper were 5 infants and 1 preschool age. Facility is still out of compliance because plan of correction has not been met. Civil penalty $100 is assessed today.

Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

You will receive a bill in the mail. Payment is due when billed. Payment must be made by personal, business or cashier check or a money order made payable to the California Department of Social Services. Please write the facility number and invoice number on your check and include a copy of your bill with the payment. You will find the invoice number on your bill. DO NOT SEND CASH.

Exit interview conducted and report was reviewed with the Licensee, Guadalupe Clark. A Notice of Site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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 04/29/2022 04:08 PM - It Cannot Be Edited


Created By: Monica Mathur On 04/29/2022 at 02:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2022
Section Cited
CCR
102416.5(d)(1)

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102416.5 Staffing Ratio & Capacity (d) for a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:(1) Twelve children, no more than four of whom may be infants. This requirement is not met as evidenced by:
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By POC Due Date 4/28/22 Licensee agreed to send a written plan on how they will bring facility into compliance with respect to ratios and number of infants present at one time which shall not exceed 4.
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Per LPA's inspection, present in the home today are 5 infants and 1 preschool age with Licensee and Helper. Licensee is out of ratio by 1 extra infant. This poses an immediate risk to health and safety of children 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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