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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243909809
Report Date: 08/26/2021
Date Signed: 08/26/2021 10:11:48 AM

Document Has Been Signed on 08/26/2021 10:11 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:AYALA, MANUEL & DOMINICA FAMILY CHILD CAREFACILITY NUMBER:
243909809
ADMINISTRATOR:AYALA, MANUEL & DOMINICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 384-3643
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dominica AyalaTIME COMPLETED:
10:15 AM
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On 08/26/2021 Licensing Program Analysts (LPAs) Rene Mancinas and Roman Iglesias, conducted an unannounced case management inspection. LPAs met with Licensee, Dominica Ayala. Dominica contacted her husband, Manual Ayala, who is also a licensee, via video/facetime so that he could be virtually present during today’s inspection. The purpose of inspection was to provide Licensees with a notification letter of immediate exclusion for adult son, Joel Damien Ortega, which informs Licensees that Joel Damien Ortega is excluded from being present in all facilities licensed by the Department. Licensees are to ensure Joel Damien Ortega be immediately excluded from having contact with day care children or being physically present at (any) facility. Licensees were advised exclusion order remains in place, unless otherwise notified in writing by the Department. LPAs provided Licensees with information/rights to appeal Department’s order within 15 days of today’s service notification. Licensee, Dominica Ayala, signed a copy of order acknowledging receipt. Dominica was provided with original copy of order.

In addition, LPAs provided Licensees with copies of LIC 995B ‘Family Child Care Home Addendum To Notification of Parent’s Rights (Regarding Removal/Exclusion). LPAs informed Licensees they are to provide LIC 995B form to parents by the end of day, or by the next time day child(ren) are in care. Licensees understand parents are to sign LIC 995B acknowledging receipt of notification, and the form must be stored in children file, and subject to review/verification by the Department during future inspections.

Per California Code of Regulations Title 22 Division 12 Chapter 3, no deficiency is being cited today. Notice of Site to be posted for 30 days.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Rene Mancinas
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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