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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403445
Report Date: 08/13/2021
Date Signed: 08/13/2021 04:30:17 PM

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:ZAVALA, KARENFACILITY NUMBER:
073403445
ADMINISTRATOR:ZAVALA, KARENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 252-1485
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:14CENSUS: 8DATE:
08/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karen ZavalaTIME COMPLETED:
04:30 PM
NARRATIVE
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On 8/13/21 at 2:00 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an Initial Complaint Investigation at Karen Zavala Child care. LPA met with licensee, Karen and explained the purpose of today's investigation. Today present during the inspection there were 8 children and Alexa Gonzales who is helping with care of children. LPA reminded licensee that when there is no assistant present for daycare, licensee must operate as a small family child care. LPA reminded licensee the ratios to be in compliance for a day care home.
Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.

At 4:00 PM during today's inspection a citation will be issued today for criminal record clearances for Alexa Gonzales with a civil penalty of $500 ($100 per person per day for a maximum 5 days). Due to the issuance of a Type A citation during today's inspection, a copy of this Licensing Report must be posted in the facility and given to each existing parent by the end of today or next day child is in care. Report also has to be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

Exit Interview was conducted with Karen, where this report, citation, civil penalty was reviewed and discussed. Report was signed by Karen confirming receipt of documents. A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE HOME FOR 30 CONSECUTIVE DAYS AND APPEAL RIGHTS WERE GIVEN.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ZAVALA, KAREN
FACILITY NUMBER: 073403445
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2021
Section Cited

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102370(d)(1) Criminal Record Clearance: 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
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This requirement is not met as evidence by 1 adult is assisting with children without fingerprint clearances, this is an immediate risk to the health and safety of children. Civil Penalty of $500 assessed.
Amanpreet Kaur and Pardeep Kaur.
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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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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