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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243904693
Report Date: 08/06/2021
Date Signed: 08/06/2021 10:04:32 AM

Document Has Been Signed on 08/06/2021 10:04 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CAREFACILITY NUMBER:
243904693
ADMINISTRATOR:GAMA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 383-6804
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria Gama - LicenseeTIME COMPLETED:
10:15 AM
NARRATIVE
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On 8/6/21 Licensing Program Analyst (LPA), Joseph Pacheco arrived at the family day care home to conduct an unannounced Case Management inspection to clear deficiencies cited on 7/7/21. LPA observed the children's files that were missing LIC995A Notification of Parent's Rights and LIC627 Consent for Emergency Medical Treatment now contain the required forms. LPA cleared the deficiency on this date and provided licensee with a "Letter of Deficiency Citations Cleared."

During today's inspection LPA observed Adult #1 in the home. A review of the fingerprint clearance roster showed that Adult #1 has been fingerprint cleared by the FBI and DOJ but not the Child Abuse Clearance Index as required.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D).

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the LIC 9224 was given to licensee.

Licensee was provided a copy of appeal rights. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
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 08/06/2021 10:04 AM - It Cannot Be Edited


Created By: Joseph Pacheco On 08/06/2021 at 09:35 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: GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CARE
FACILITY NUMBER: 243904693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2021
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as
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Licensee stated she will have Adult #1 obtain a criminal record clearance and submit proof to CCL by 8/9/2021.
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evidenced by LPA observation of Adult #1 in the home and statement from Licensee that Adult #1 resides in the home. This is an immediate risk to the health, safety, or personal rights of children in care. An $100 Civil Penalty is being assessed.
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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:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021


LIC809 (FAS) - (06/04)
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