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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243911534
Report Date: 10/20/2022
Date Signed: 11/30/2022 10:22:53 AM

Document Has Been Signed on 11/30/2022 10:22 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:LOPEZ PEREZ, MONICA FAMILY CHILD CAREFACILITY NUMBER:
243911534
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
10/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monica Lopez Perez TIME COMPLETED:
12:45 PM
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This is an amended version of the original report dated on 10/20/22.

On 10/20/22 Licensing Program Analyst (LPA) Araceli Gibson conducted an unannounced case management incident inspection. LPA met with Spanish speaking Licensee, Monica Lopez Perez. LPA Gibson followed up on an incident that was reported to CCL in 10/04/22. The incident involved an injury to a child. On 10/04/22 child (1) was at the park and ran into a bench. Licensee immediately went to the child to see the injury. The child (1) was bleeding under his chin. The Licensee applied pressure with a sweater, and they walked home. Licensee called the mother. Mother was unable to come or take the child to the emergency room, because she was working in Salinas. Licensee stated he needed medical attention. Mother requested the Licensee to take him to the Memorial Hospital where the child was treated and given six stiches. The child (1) returned to care on 10/06/22. LPA Gibson discussed the Licensee should be reaching out to emergency contacts and speaking with authorized representatives about their responsible for providing emergency contacts for this purpose should another incident occur while caring for other children. LPA took a photo of the LIC 624 for CCLD Records.

The Licensee was providing adequate supervision during the incident, notified authorized representative and provided medical treated to the child by request from authorized representative given the situation, reported, and properly documented the incident with Community Care Licensing.

No deficiencies were issued for today's visit. Exit interview conducted with the Monica Lopez Perez.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Araceli Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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