<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624876
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:12:34 PM

Document Has Been Signed on 06/19/2023 03:12 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FARFAN, LORINDAFACILITY NUMBER:
293624876
ADMINISTRATOR:FARFAN, LORINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 823-7311
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95949
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
06/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lorinda FarfanTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 1:10pm on 6/19/2023, Licensing Program Analyst (LPA) Matthew Gallo met with licensee Lorinda Farfan for the purpose of opening a complaint investigation. At time of arrival, LPA observed 4 children supervised by licensee.

When approaching the home, LPA observed on the front deck a portable plastic pool several feet in diameter that was filled with standing water. At that time, licensee was inside putting one of the children down to nap while providing supervision to the three other children in care. Licensee states that she had filled it up prior to LPA arrival with the intention of using it. The chilly weather prevented use, and licensee was about to empty it after putting a restless child down to nap.

A Title 22 Deficiency is cited on the accompanying LIC809-D

Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days 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. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 was provided.

An immediate civil penalty of $500 is assessed for violating regulations regarding standing bodies of water. See LIC-421IM

Licensee corrected deficiency on-site while LPA was present.

Exit interview conducted and report was reviewed with the licensee Lorinda Farfan. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/19/2023 03:12 PM - It Cannot Be Edited


Created By: Matthew Gallo On 06/19/2023 at 02:45 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FARFAN, LORINDA
FACILITY NUMBER: 293624876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2023
Section Cited
CCR
102417(g)(5)

1
2
3
4
5
6
7
All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will empty pool while LPA is present.
8
9
10
11
12
13
14
Upon arrival to facility, LPA observed on the front deck a portable plastic pool, several feet in diameter, that was filled with water. The pool did not have a necessary fence or cover to prevent access to children.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Keven Peters
LICENSING EVALUATOR NAME:Matthew Gallo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2