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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409194
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:57:10 AM

Document Has Been Signed on 08/25/2023 11:57 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ROMO, CRISTINAFACILITY NUMBER:
073409194
ADMINISTRATOR:ROMO, CRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 375-4269
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
08/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:ROMO, CRISTINATIME COMPLETED:
12:15 PM
NARRATIVE
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On August 25, 2023 at 9:10AM Licensing Program Analyst (LPA) Nyeesha Blount was conducting an unannounced complaint investigation while verifying names on facility profile it was observed Licensee Assistant Mayra Romo( licensee sister) is NOT Fingerprint Cleared to be working in the facility. LPA explained again to the Licensee that PRIOR to having contact with children, all person's 18 years of age or older, who live, work or reside in the home, must be fingerprint cleared! A deficiency was cited at this visit. Please see 809D for the deficiency.

Exit interview conducted, Notice of site visit given and Appeal rights. Report was read and left with licensee Romo, Cristina.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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Document Has Been Signed on 08/25/2023 11:57 AM - It Cannot Be Edited


Created By: Nyeesha Blount On 08/25/2023 at 10:08 AM
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: ROMO, CRISTINA
FACILITY NUMBER: 073409194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
102370(d)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.

This requirement was not met as evidenced by..
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By the POC due date of September 15, 2023; Licensee will provide proof of fingerprint clearnace.
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Based on LPA's observation Mayra Romo was not fingerprint cleared and is working in the home with the children in care. An immediate civil penalty is being accessed for $500 on this date.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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