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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573607570
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:25:37 PM

Document Has Been Signed on 04/29/2024 02:25 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LARA, GUADALUPEFACILITY NUMBER:
573607570
ADMINISTRATOR/
DIRECTOR:		LARA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 574-0121
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
04/29/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Guadalupe LaraTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Manager (LPM) Karyn Guerra and Licensing Program Analyst (LPA) Jennie Tedlos, met with Licensee, Guadalupe Lara, for the purpose of an informal/office meeting. Today's meeting was conducted at the facility.
LPM defined the difference between Non-Compliance and an Informal meeting. LPM advised that the purpose of today's meeting is to help the facility gain compliance.

Today's informal meeting was to discuss the Type A and B citations issued from 12/28/2023-02/14/2024
during Complaint, Required – 1 Year, and Case Management Inspections.
On 12/28/2023 the facility was cited 2 type A citations regarding Criminal Record Clearances.
On 02/14/2024 the facility was cited a type A citation regarding Inimical Conduct.
On 02/14/2024 the facility was cited a type B citation regarding Reporting Requirements.

The Licensee stated that they have taken the following steps to maintain compliance:
1. Licensee does not allow the removed individual in the facility when children in care are present.
2. Licensee does not allow the removed individual in the facility during operating hours.
3. Licensee provided an updated application for the adult living in the home.

LPA and LPM reviewed Criminal Record Clearances, and Criminal Record Exemptions and Denials. LPM discussed and explained the Confirmation of Removal and Addendum to Notification of Parent's Rights Forms. LPM explained reporting requirements for new adults living in the home.

This report was reviewed by Licensee Guadalupe Lara.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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