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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103910754
Report Date: 11/12/2025
Date Signed: 11/12/2025 02:41:49 PM

Document Has Been Signed on 11/12/2025 02:41 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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:PEREZ, JACQUELINE FAMILY CHILD CAREFACILITY NUMBER:
103910754
ADMINISTRATOR/
DIRECTOR:		PEREZ, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 375-0269
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
11/12/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Siena PerezTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On 11/12/2025 Licensing Program Analyst (LPA) Pa Kou Vue conducted an unannounced Annual Required Inspection and was met by A1. A2 and Licensee arrived later during the inspection. LPA explained to Licensee the purpose of today’s inspection. Licensee stated days and hours of operation are Monday to Friday from 6:30AM – 5:30PM. The home has a working telephone service and LPA confirmed the phone number.

LPA toured the home inside and outside and a census was taken. This is a two-story and stairs are not properly gated when children under age 5 years old are present. LPA observed white metal stairs located in accessible family room that lead to the second floor. Placed loosely on the second step of stairs is a gray baby gate. LPA tugged against the gate, and the gate fell. The gate is NOT installed or used according to manufacturer's guidelines. Furthermore, between each stair rod there is at least a one-foot gap. LPA was easily able to slide safety gate out. LPA addressed observations and concerns with Licensee. Licensee stated they understood and will ensure compliance moving forward. Capacity as specified on the license is being maintained. LPA reviewed current facility sketch and confirmed that the kitchen, living room, dining room, family room – play area, bedroom 3 and bedroom 3’s restrooms are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of baby gates and doorknob levers. Safe toys and play equipment are observed. LPA inspected the restroom and observed the restroom to be clean and sanitized. The sink and toilet are functioning properly within.

There is one fireplace in the home located in the accessible living room and is made inaccessible by a screen gate and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Jose Penate
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/12/2025 02:41 PM - It Cannot Be Edited


Created By: Pa Kou Vue On 11/12/2025 at 02:15 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PEREZ, JACQUELINE FAMILY CHILD CARE
FACILITY NUMBER: 103910754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA onservations and Licensee interview, the licensee did not comply with the section cited above. This is a two-story and stairs are not properly gated when children under age 5 years old are present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
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Licensee stated she will properly install a child safety gate around the stairs and make it inacessible when children under 5 are present and will submit pictures to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Jose Penate
NAME OF LICENSING PROGRAM MANAGER:
Pa Kou Vue
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


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: PEREZ, JACQUELINE FAMILY CHILD CARE
FACILITY NUMBER: 103910754
VISIT DATE: 11/12/2025
NARRATIVE
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Licensee stated there are no firearms or ammunition on the premises. Licensee stated there are no poisons stored on the premises. Licensee stated there is no smoking on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

Licensee stated and LPA confirmed the backyard is off-limits. LPA reminded Licensee prior to daycare children accessing backyard, the department must be contacted to approve the off-limits backyard. Licensee stated she understood. LPA reminded Licensee to maintain supervision of children at all times when engaged in water activities. LPA referred Licensee to PIN 21-16-CCLD: Seasonal Reminder of Water Safety Requirements and Measures.

Licensee has pets on the premises. Licensee is aware of the safety of children around animals. Licensee understands her liability and responsibility regarding pets.

Licensee ensures that children in care are always supervised 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.

LPA reviewed a sample of children’s files and observed files were not complete with emergency information and all required forms were not present and completed as required. Based on LPA children’s records review, C5 is missing the second page of LIC700. Furthermore, C1 is missing immunization records. LPA addressed observations with Licensee. Licensee stated she will complete the requested and maintain copy in child's file.

A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis, and measles. All staff files were complete with necessary forms and signed appropriately.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

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. Guardian background criminal record clearances were verified and discussed with Licensee Jacqueline Perez and was signed.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Jose Penate
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: PEREZ, JACQUELINE FAMILY CHILD CARE
FACILITY NUMBER: 103910754
VISIT DATE: 11/12/2025
NARRATIVE
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During the exit interview, Licensee Jacqueline Perez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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-andresources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for and removing any 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.

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/.

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.

Exit interview conducted and report was reviewed with Licensee Jacqueline Perez.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiency is being cited: (see LIC 809-D for further details).

Licensee was provided appeal rights.

This report shall be made available to the public upon request. LIC 9213 A Notice of Site Visit is provided and required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Jose Penate
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
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