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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911103
Report Date: 04/12/2024
Date Signed: 04/22/2024 01:51:34 PM

Document Has Been Signed on 04/22/2024 01:51 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:COSTA, KIMBERLY FAMILY CHILD CAREFACILITY NUMBER:
503911103
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Paris CostaTIME VISIT/
INSPECTION COMPLETED:
12:41 PM
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On 04/12/2024 Licensing Program Analyst (LPA), Anita Tristan and Licensing Program Manager (LPM) Cynthia Brannon conducted an unannounced Annual Required Inspection and was met by Licensee’s Assistant 1. Licensee, Kimberly Costa was not present at the time of inspection. Days and hours of operation are Monday through Friday from 7:30am to 5:30pm. There were 6 children present during today’s inspection.

LPA toured the home inside and outside and a census was taken. LPA reviewed current facility sketch and confirmed that the kitchen, bathroom and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible using a baby gates.

LPA observed there is no swimming pool or other bodies of water on the premises.

Per licensee there are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort.

This is a single level home and there are no stairs. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (209) 202-0822.

***Continued on 809-C***

SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 04/12/2024
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. The outdoor play area in the backyard is fenced. The children had not been outside to play when LPA arrived at facility. LPA observed dog feces on a green outdoor carpet, two broken fence pickets, spider webs in the outside playhouse, power mower and three 5-gallon paint containers accessible to children in care. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files, observed two children did not have files and siblings were sharing forms. LPA discussed with licensee that each child needs to have their own individual file and children’s files are to be complete with emergency information as required. Licensee’s Mandated Reporter Training expired on 08/2023. Licensee’s pediatric CPR/First Aid certification expires on 04/30/2025. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis, and measles.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

***Continued on 809-C***

SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 04/12/2024
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. The outdoor play area in the backyard is fenced. The children had not been outside to play when LPA arrived at facility. LPA observed dog feces on a green outdoor carpet, two broken fence pickets, spider webs in the outside playhouse, power mower and three 5-gallon paint containers accessible to children in care. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files, observed two children did not have files and siblings were sharing forms. LPA discussed with Assistant 1 that each child needs to have their own individual file and children’s files are to be complete with emergency information as required. Licensee’s Mandated Reporter Training expired on 08/2023. Licensee’s pediatric CPR/First Aid certification expires on 04/30/2025. A review of records indicates that all employees did no have immunization records on file for influenza, pertussis, and measles.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

***Continued 08 809-C***

SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 04/12/2024
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LPA discussed safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care licensing/public-information-and resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility does not provide Incidental Medical Services – IMS. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with Licensee's Assistant 1. Appeal rights were provided and discussed.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA verified the RSO profile in FAS.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page).

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2024 01:51 PM - It Cannot Be Edited


Created By: Anita Tristan On 04/12/2024 at 12:30 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation licensee did not have current AB1207, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licnesee will obtain AB1207 and submit a copy by POC date of 04/26/2024.
Licensign Program Analyst will review during POC visit.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not having complete children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensign Program Analyst will review childrrens files during POC visit.
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:Cynthia Brannon
LICENSING EVALUATOR NAME:Anita Tristan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


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