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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203911867
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:59:57 PM

Document Has Been Signed on 10/12/2022 02:59 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:SALAS, INOCENCIA FAMILY CHILD CAREFACILITY NUMBER:
203911867
ADMINISTRATOR:SALAS, INOCENCIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 430-8585
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:INOCENCIA SALASTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA), Stephanie Vega-Gonzalez, conducted an unannounced case management inspection at the facility. LPA met with Licensee Inocencia Salas to discuss a Confirmation of Removal form that was mailed to the Licensee's mailing address from Department of Social Services, Caregiver Background Check Bureau, on August 29, 2022. LPA toured facility inside and outside and did not oversee Adult #1 in the home, and took a census.

LPA asked Licensee if she had received the Confirmation of Removal form. Licensee stated she had and had submitted it to licensing via mail. LPA explained to Licensee that Adult #1 cannot work, reside, or be present at this facility unless a criminal record exemption is granted. Pursuant to state law, an exemption may be granted if the Caregiver Background Check Bureau (CBCB) is in receipt of substantial and convincing evidence that the individual is of present good character. Licensee indicated the individual named on the form has not been present or worked at the facility since approximately March 1, 2022. Licensee Inocencia Salas signed LIC 300B CONFIRMATION OF REMOVAL FOR: Adult #1 who is no longer present or employed at this facility.

Based on the evidence obtained during today’s visit, the LPA has verified that Adult #1 is no longer present or employed at this facility since approximately March 1, 2022. LPA has advised the licensee to disassociate the individual from their roster.


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

An exit interview was conducted with licensee. Notice of Site Visit 9213 will be posted for 30 days


Verification of removal is complete.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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