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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911103
Report Date: 05/01/2024
Date Signed: 05/02/2024 11:01:47 AM

Document Has Been Signed on 05/02/2024 11:01 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:COSTA, KIMBERLY FAMILY CHILD CAREFACILITY NUMBER:
503911103
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:24 PM
MET WITH:Kimberly CostaTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 05/01/2024 Licensing Program Analyst (LPA) Anita Tristan and Licensing Program Manager (LPM) Cynthia Brannon, conducted an unannounced POC Inspection and was met by Licensee’s daughter/assistant and Licensee, Kimberly Costa.

LPA and LPM explained the reason of the visit. LPA and LPM reviewed the citations from inspection dated 04/12/2024. Licensee did not correct the citations issued on 4/12/24 with a POC date of 04/26/2024. LPM explained to Licensee that due to Licensee, not making the required correction, a civil penalty is warranted.

Per licensee, she is requesting an extension to her POC date. Licensee is to provide copies of requested documentation to Fresno Community Care Licensing office, no later than May 3, 2024, by 10:00 AM. LPA provided her business card with her email address. Per licensee, she will be forwarding corrections by email to LPA Anita Tristan.

An exit interview was conducted with licensee, Kimberly Costa, and assistant. No deficiencies were issued during today’s inspection. A Notice of Site Visit and Appeal Rights were provided during today’s inspection will be provided via email.

SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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