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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153905008
Report Date: 09/29/2022
Date Signed: 09/29/2022 01:44:10 PM

Document Has Been Signed on 09/29/2022 01:44 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:BENITEZ, AGATHA FAMILY CHILD CAREFACILITY NUMBER:
153905008
ADMINISTRATOR:BENITEZ, AGATHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 717-3202
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Agatha Benitez - Licensee TIME COMPLETED:
02:00 PM
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On 9/29/2022, an unannounced Case Management - Plan of Correction (POC) Inspection was conducted by Licensing Program Analyst (LPA) Jessika Thompson. LPA met with Licensee Agatha Benitez to review the POC's associated to deficiencies cited on 9/02/22. Today, LPA verified the following:

· Licensee completed Child Abuse Mandated Reporter training on 9/2/2022
· Licensee maintains proof of required immunization on file for Staff #2
· Licensee maintains Emergency Medical Information for children in care
· Licensee maintains Liability Insurance Affidavits on file for children in care
· Licensee maintains proof of immunization for children in care

LPA cleared deficiencies previously cited on this date and provided licensee with a Letter of Deficiency Citations Cleared. This letter must be filed in the facility for three years and upon request made accessible to the public for review.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Jessika Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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