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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911103
Report Date: 05/15/2025
Date Signed: 05/15/2025 04:05:49 PM

Document Has Been Signed on 05/15/2025 04:05 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 RO, 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: 5DATE:
05/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Kimberly CostaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 05/15/2025 Licensing Program Analyst (LPA) Pa Kou Vue conducted an unannounced Annual Required Inspection and was met by facility representative - Assistant who is also the Licensee's daughter. LPA explained the purpose of today’s inspection. LPA conducted interviews with facility representative; however, LPA reviewed LIC809 report with Licensee who arrived later in the inspection. Days and hours of operation are Monday to Friday, 7:30AM – 5:30PM. The home has working telephone service and LPA confirmed the phone number is 209-202-0822.

LPA toured the home inside and outside and a census was taken. This is a single level home and there are no stairs. Capacity as specified on the license is being maintained. LPA reviewed current facility sketch and confirmed that the living room, kitchen, backyard, bedroom #2, bedroom #3, hallway bathroom and bedroom #1 are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of a baby gate and doorknob spinners. Safe toys and play equipment’s are observed. LPA inspected the restroom and observed the restroom to be clean and sanitized. The sink and toilet are functioning properly within.

LPA observed on 1 of the 3 infants a pacifier with an attached clip; however, the clip was NOT attached to the infant. LPA reminded facility representative the department's regulation. Facility representative stated she understood.

LPA was informed a child was sleeping in accessible bedroom #1. LPA followed facility representative and observed that the door to bedroom #1 was closed. LPA reviewed the department's regulation with facility representative. Facility representative stated she understood.

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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Juvenal Moctezuma
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/15/2025 04:05 PM - It Cannot Be Edited


Created By: Pa Kou Vue On 05/15/2025 at 03:06 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: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(6)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (6) Outdoor play areas shall be either fenced, or outdoor play areas shall be supervised by the licensee Section 102417(g)(5).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above, in the accessible backyard LPA observed a loose wooden plank and numerous at least 5-inch nails protruding from the wooden fence. Facility representative stated daycare children were in the backyard earlier today for at least 2 hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Facility representative they will fix the wooden plank and protruding nails and submit pictures to LPA via email by end of business 5/23/2025.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA records review and interview, the licensee did not comply with the section cited above in 2 of 3 infants in care did not have LIC9227 and 3 out of 3 infants did not have 15 minute sleep logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Facility representative they will complete LIC9227 and 15 minute sleep logs for both infants and submit copies to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Juvenal Moctezuma
NAME OF LICENSING PROGRAM MANAGER:
Pa Kou Vue
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


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 RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 05/15/2025
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The outdoor play area in the backyard is fenced and there are hazards to children present. LPA observed in accessible backyard a loose wooden plank and numerous at least 5-inch nails protruding from the wooden fence. Facility representative stated daycare children were in the backyard earlier today for at least 2 hours.

LPA observed in accessible backyard children’s toys and play equipment’s along with cobwebs. Facility representative stated the children were in the backyard earlier today for at least 2 hours. LPA reminded facility representative to sweep play toys and equipment’s free of cobb web prior to daycare children accessing the backyard. Facility representative stated she understood.

Licensee was reminded to conduct daily inspections of the outdoor area and on the outdoor play structures and equipment’s for normal wear and tear overtime, to be free of loose, pointed, or sharp edges prior to day-care children accessing outdoor area.

There is no swimming pool or other bodies of water on the premises. LPA reminded Licensee that she must maintain supervision of children at all times when engaged in water activities. LPA referred Licensee to PIN 21-16-CCLD: Seasonal Reminder of Water Safety Requirements and Measures.

Licensee has pets on the premises. Licensee is aware of the safety of children around animals. Licensee understands her liability and responsibility regarding pets.

Licensee stated there are no firearms or ammunitions on the premises. Licensee stated there are no poisons stored on the premises. Licensee stated there is no smoking on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

Licensee ensures that children in care are always supervised and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

LPA reviewed a sample of children’s files and observed files were not complete with emergency information and all required forms were present and completed as required.

Upon LPA records review and facility representative interview, 2 of 3 infants are missing LIC9227 and 3 of 3 infants are missing their 15-minute sleep logs.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Juvenal Moctezuma
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 05/15/2025
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Assistant’s Mandated Reporter Training expires on 12/07/2025. Assistant’s pediatric CPR/First Aid certification EXPIRED 04/30/2025. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis, and measles. All staff files were complete with necessary forms and signed appropriately.

LPA conducted records review and interview, Licensee and Assistant's CPR/Pediatric First Aid EXPIRED 04/30/2025. LPA verified that Licensee and Assistant has a scheduled appointment for 05/20/2025.

Upon LPA records review and interview, Assistant is missing immunization records for MMR and Tdap in file.

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 Childcare 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. Guardian background clearances were verified by Licensee.

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. Guardian background clearances were verified and discussed with Licensee.

LPA discussed safe sleep regulations with Licensee and discussed the Childcare Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Juvenal Moctezuma
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 05/15/2025
NARRATIVE
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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 Kimberly Costa.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencies are being cited: (see 809-D for further details).

Licensee was provided appeal rights.

This report shall be made available to the public upon request. LIC 9213 A Notice of Site Visit is provided and required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Juvenal Moctezuma
NAME OF LICENSING PROGRAM ANALYST: Pa Kou Vue
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
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