<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 545620287
Report Date: 05/29/2025
Date Signed: 05/29/2025 10:25:16 AM

Document Has Been Signed on 05/29/2025 10:25 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 SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:PEREZ, MARTHA FAMILY CHILD CAREFACILITY NUMBER:
545620287
ADMINISTRATOR/
DIRECTOR:		PEREZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 280-5883
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:19 AM
MET WITH:Martha PerezTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 29, 2025, Licensing Program Analyst (LPA) Paul Garcia conducted an unannounced Case Management Incident inspection. LPA met with Martha Perez, with Staff 1 (S1) also present. LPA Garcia toured the facility inside and outside and took a census. The purpose of this inspection was to discuss an unusual incident reported to Fresno Community Care Licensing Division (CCLD) on May 28, 2025, involving Child 1 (C1), who sustained fractures to the distal radial and ulna bones in her left arm/wrist.

Incident Summary

On May 23, 2025, at approximately 12:45 PM, two children were playing on a backyard play structure under S1’s supervision. C1 was using the monkey bars when she lost her grip, fell, and sustained a minor forehead scrape. S1 immediately attended to C1, comforting her and checking for injuries. C1 cried for about 15 minutes but then resumed playing actively for an hour, had a snack at 2:00 PM, and later took a nap.

Since no apparent injury beyond the scrape was observed, and C1 did not express discomfort, parents were not initially notified. Upon C1’s mother’s arrival at approximately 4:00 PM, she was informed of the incident.

Medical Evaluation

Later that evening, at 6:21 PM, C1’s parent took her to Adventist Health Tulare, located at 869 Cherry St., Tulare, California 93274, where she was diagnosed with fractures to the distal radial and ulna bones in her left arm/wrist. Discharge instructions included a follow-up with her primary care provider and Valley Children’s Hospital to determine if a hard cast was necessary.

C1 and her sibling have since returned to care with no irregular gaps or restrictions.

NAME OF LICENSING PROGRAM MANAGER: Cynthia Brannon
NAME OF LICENSING PROGRAM ANALYST: Paul Garcia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PEREZ, MARTHA FAMILY CHILD CARE
FACILITY NUMBER: 545620287
VISIT DATE: 05/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility Review and Compliance

LPA Garcia interviewed Martha Perez and S1, inspected the play structure, and determined it was age-appropriate for C1 and that proper supervision was in place. However, upon reviewing documents and conducting interviews, it was determined that Martha Perez failed to notify the department by the next business day regarding C1’s injury requiring medical attention.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D)

An exit interview was conducted, and this report was reviewed with Martha.


A notice of site visit was issued and must remain posted for 30 days.
This report shall be made available to the public upon request.
NAME OF LICENSING PROGRAM MANAGER: Cynthia Brannon
NAME OF LICENSING PROGRAM ANALYST: Paul Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/29/2025 10:25 AM - It Cannot Be Edited


Created By: Paul Garcia On 05/29/2025 at 09:53 AM
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: PEREZ, MARTHA FAMILY CHILD CARE
FACILITY NUMBER: 545620287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2025
Section Cited
CCR
102416.2(a)(3)(B)

1
2
3
4
5
6
7
Reporting Requirements (a) The licensee shall report the following information the Department by telephone or fax within the Department's next business...(3) Health and Safety Code Section 1597.467(b)(1) provides in part: (B) Any injury to any child that requires medical treatment.
1
2
3
4
5
6
7
LPA provided a hard copy of the regulations related to reporting requirements. Licensee agreed to review the entire section then will sign the document, acknowledging full understanding of its contents by June 6, 2025 .
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not report an injury requiring medical treatment to the department by the next business day as required which poses a potential Health and/or, Safety and/or, Personal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cynthia Brannon
NAME OF LICENSING PROGRAM MANAGER:
Paul Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4