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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208243
Report Date: 02/09/2022
Date Signed: 02/09/2022 08:42:23 PM

Document Has Been Signed on 02/09/2022 08:42 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ENCLAVE AT THE FOOTHILLSFACILITY NUMBER:
547208243
ADMINISTRATOR:PEREZ, KRISTINAFACILITY TYPE:
735
ADDRESS:10650 ROAD 256TELEPHONE:
(559) 527-5090
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 20CENSUS: 13DATE:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Administrator Certificate Holder working as Interim Administrator at this time Francisco (Javier) Hernandez.TIME COMPLETED:
08:45 PM
NARRATIVE
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During a Complaint visit, the following deficiency was observed:

Three (3) facility staff persons (S1, S2, & S3) having worked 5 or more days were not fingerprint cleared &/or associated to this facility.

Deficiency issued
Immediate Civil Penalty issued at a rate of $100.00 per day, per person totalling $1,500.00.

Exit interview conducted with Administrator Certificate Holder working as Interim Administrator at this time Francisco (Javier) Hernandez. Reports provided. Appeal Rights provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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Document Has Been Signed on 02/09/2022 08:42 PM - It Cannot Be Edited


Created By: Kelly J. McClurg On 02/09/2022 at 07:36 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ENCLAVE AT THE FOOTHILLS
FACILITY NUMBER: 547208243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2022
Section Cited
CCR
80019(e)(1-3)

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Criminal Record Clearance - (e) All individuals subject to a criminal record review... shall prior to working, in a licensed facility: (1) Obtain a California clearance or a criminal record exemption ...(2) Request a transfer of a criminal record
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S1, S2, S3 to be removed from schedule & premises until fingerprint cleared &/or associated to this facity.
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clearance...or (3) Request and be approved for a transfer of a criminal record exemption....
Violation: S1, S2, & S3 have been working for more than 5 days without fingerprint clearance &/or being associated to this facility;
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IAdmin has agreed to submit in writting letter stating staff are removed from schedule until such time as cleared &/or associated. Copy of association may be emailed to LPA.
Immediate Civil Penalty issued for $1,500.00;

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andy Xiong
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022


LIC809 (FAS) - (06/04)
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