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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103908972
Report Date: 06/26/2024
Date Signed: 06/26/2024 11:23:03 AM

Document Has Been Signed on 06/26/2024 11:23 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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:PELAGIO, XOCHITL FAMILY CHILD CAREFACILITY NUMBER:
103908972
ADMINISTRATOR/
DIRECTOR:		PELAGIO, XOCHITLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 210-2174
CITY:HURONSTATE: CAZIP CODE:
93234
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
06/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Xochitl PelagioTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 06/26/24, Licensing Program Analyst (LPA) Martha De Haro, conducted an unannounced Annual Required Inspection and was met by Licensee, Xochitl Pelagio. The home has working telephone service and LPA confirmed the phone number is 559-210-2174. Licensee’s hours of operation are Monday through Friday, 5 am to 5 pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the kitchen, living room, dining area, daycare room, hall bathroom, and front yard are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of plastic door spinners. This is a single-story home with no stairs. The outdoor play area is located in the front yard. It is fenced and there are no hazards to children present. Licensee was reminded to clean up after her pets. Licensee stated that there is no swimming pool or other body of water on the property, which LPA confirmed via observation. Licensee stated that there are no firearms and ammunition in the home. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The home does not have a fire place or open face heaters. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Safe toys and play equipment are observed. There are 4 dogs in the home. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets.

(Continued on LIC 809-C)
SUPERVISORS NAME: Scott Herring
LICENSING EVALUATOR NAME: Martha DeHaro
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 06/26/2024 11:23 AM - It Cannot Be Edited


Created By: Martha DeHaro On 06/26/2024 at 10:45 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Licensing Program Analyst (LPA) observed that licensee's Mandated Reporter Training had expired.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee agreed to complete Mandated Reporter Training for Child Care Providers and will show proof of completion to the Community Care Licensing (CCL) Office by the Plan of Correction due date, 07/12/24. Training can be completed at mandatedreporterca.com.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Licensing Program Analyst (LPA) observed that licensee's pediatric CPR/First Aid training had expired as of last year.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee agreed to complete Pediatric CPR/First Aid and will show proof of completion to the Community Care Licensing (CCL) Office by the Plan of Correction due date, 07/12/24.
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:Scott Herring
LICENSING EVALUATOR NAME:Martha DeHaro
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972
VISIT DATE: 06/26/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were mostly complete. Licensee agreed to obtain any missing or incomplete forms as soon as possible. Licensee’s Mandated Reporter Training was completed on 06/25/21 and is expired. Licensee’s pediatric CPR/First Aid expired on 06/19/23. Licensee to complete updated trainings by her Plan of Correction due date.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/. (Continued on LIC 809-C)
SUPERVISORS NAME: Scott Herring
LICENSING EVALUATOR NAME: Martha DeHaro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PELAGIO, XOCHITL FAMILY CHILD CARE
FACILITY NUMBER: 103908972
VISIT DATE: 06/26/2024
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LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies were cited during today’s inspection (See LIC 809-D).

Exit interview conducted and report was reviewed with the licensee Xochitl Pelagio.
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A notice of site visit was given and must remain posted for 30 days. Appeal Rights were also given to licensee.
SUPERVISORS NAME: Scott Herring
LICENSING EVALUATOR NAME: Martha DeHaro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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