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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153910963
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:00:38 PM

Document Has Been Signed on 05/05/2022 03:00 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:IZARRARAS, RAQUEL FAMILY CHILD CAREFACILITY NUMBER:
153910963
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Raquel Izarraras - Licensee TIME COMPLETED:
03:15 PM
NARRATIVE
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On this date, an unannounced Case Management - Plan of Correction (POC) Inspection was conducted by Licensing Program Analyst (LPA) Jessika Thompson. LPA met with Licensee Raquel Izarraras to review the POCs associated to deficiencies cited on 4/15/22.

Today LPA conducted a post citation file review. Licensee provided proof of PM 286 completion for non-school age children enrolled in care (proof of correction clearance was provided to licensee regarding this deficiency); however, licensee stated that she has yet to obtain immunization records herself and Staff #1.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Licensee was provided a copy of appeal rights.

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: Diana deLeon
LICENSING EVALUATOR NAME: Jessika Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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Document Has Been Signed on 05/05/2022 03:00 PM - It Cannot Be Edited


Created By: Jessika Thompson On 05/05/2022 at 02:32 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: IZARRARAS, RAQUEL FAMILY CHILD CARE
FACILITY NUMBER: 153910963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
HSC
1597.622(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files reviewed, as licensee was unable to provide proof of immunization for herself and Staff #1.
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Licensee stated she will submit proof of immunzation for herself and Staff #1 to the Fresno Community Care Licensing Office by 5/26/2022
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This poses a potential health, safety or personal rights risk to persons in care.
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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:Diana deLeon
LICENSING EVALUATOR NAME:Jessika Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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