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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543904138
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:46:41 PM

Document Has Been Signed on 05/12/2022 01:46 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CHAVEZ, GUADALUPE FAMILY CHILD CAREFACILITY NUMBER:
543904138
ADMINISTRATOR:CHAVEZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 793-1239
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Guadalupe ChavezTIME COMPLETED:
02:00 PM
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On 5/12/2022, Licensing Program Analyst (LPA) Ruby Ocegueda conducted a case management inspection for the purposes of addressing a civil penalty that was assessed on 4/11/2022. Today, LPA Ocegueda met with licensee Guadalupe Chavez. LPA toured the facility and a census was taken.

On 4/11/2022, a 500.00-dollar civil penalty was assessed for a violation under California Code of Regulations 102370(d) – Criminal Record Clearance. Although the citation and civil penalty was warranted and cited correctly, the incorrect civil penalty form was used and signed by both licensee and LPA Ocegueda. Today, the correct civil penalty form (LIC 421BG) was printed and completed with licensee and signed and dated with today’s date of 5/12/2022. Two copies of LIC 421BG with appeal rights were printed, signed and licensee kept one copy for her records.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited today.

An exit interview was conducted with licensee. Notice of Site Visit 9213 will be posted for 30 days.

SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ruby Ocegueda
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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