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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623873
Report Date: 02/10/2023
Date Signed: 02/10/2023 09:30:27 AM


Document Has Been Signed on 02/10/2023 09:30 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:14CENSUS: 6DATE:
02/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melina JimenezTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Amanda Blesi arrived at the home at approximately 8:30AM on 2.10.23 to verify the gate to the pond in the backyard will self close and self latch. Upon arrival there were five day care children present and one additional child arrived during the inspection. Also present were licensee's mother and father in law. All adults present today have a fingerprint clearance.

During the annual inspection conducted on 1.25.23, the gate for the backyard pond could not be tested due to severe flooding and thick mud from recent storms near the entrance to the gate. During the inspection today, LPA was able to verify that the gate self closed and self latched when tested.

A deficiency was issued during the annual inspection when licensee could not locate her First aid/CPR card. Licensee states she still cannot find her card so she is registered to take a new course on 2.21.23. Licensee will submit a current valid card to LPA upon completion of the course to correct the deficiency.

No deficiencies cited during today's inspection.
Exit interview with Melina Jimenez.
Notice of Site Visit provided which must be posted for 30 days or civil penalties will apply.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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