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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910105
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:21:16 PM

Document Has Been Signed on 07/28/2021 03:21 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:DIAZ, CLEMENTINA FAMILY CHILD CAREFACILITY NUMBER:
543910105
ADMINISTRATOR:DIAZ, CLEMENTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 232-4255
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
07/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diaz, ClementinaTIME COMPLETED:
03:40 PM
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On 7/28/2021, Licensing Program Analysts (LPAs) Ruby Ocegueda and Stephanie Galvan conducted an unannounced case management inspection. LPA's took a census and toured the facility. Before entering the home, a Covid-19 inspection was conducted. LPA's Ocegueda and Galvan met with licensee Clementina Diaz.

Upon arriving, it was observed that front yard of the home had a large opening at the front chain link fence that separates the yard from the street. The street has heavy vehicle traffic. On the ground was fallen branches and the mail box that was caused by the car crashing into the chain link fence. Licensee stated that the incident had just occurred last night (7/27/2021) at approximately 8:45 PM (per security cameras) and that she did report the incident to the local authorities. There were no children in care and licensee and her family were not home at the time.

Today, LPA reviewed facility sketch with licensee. Per licensee, she does not use the front or back yard at the moment due to heat and having dogs outside in the back. The back yard and front yard were marked inaccessible on the facility sketch. LPA reviewed the requirement to report Unusual Incidents via telephone to the Department within 24 hours of occurring. LIC 624 (Unusual Incident Form) was reviewed with licensee. Licensee stated she will submit the LIC 624 to the Department within 7 days.

An exit interview was conducted with licensee Clementina Diaz. Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiency is cited during today's case management inspection.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ruby Ocegueda
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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