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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573607570
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:56:07 AM

Document Has Been Signed on 12/28/2023 11:56 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LARA, GUADALUPEFACILITY NUMBER:
573607570
ADMINISTRATOR:LARA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 574-0121
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
12/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Guadalupe LaraTIME COMPLETED:
12:20 PM
NARRATIVE
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On December 28, 2023, Licensing Program Analysts (LPA’s) Lauren Scott and Jennie Tedlos conducted a case management inspection at the facility. LPAs met with Licensee, Guadalupe Lara. At time of arrival LPA's observed 2 children.

Based on observation, interview, and file review, the facility has a resident in the home that does not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Licencee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 9099-D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Licensee, Guadalupe Lara. A copy of this report and appeal rights were discussed and left for the Licensee. A Notice of Site Visit was posted by LPA’s and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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 12/28/2023 11:56 AM - It Cannot Be Edited


Created By: Jennie Tedlos On 12/28/2023 at 11:00 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LARA, GUADALUPE
FACILITY NUMBER: 573607570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
102370(a)(1)

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102370 Criminal Record Clearance: Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption.This requirement was not met as evidenced

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The licensee must not provide child care as long as LH resides in the home without a Criminal Record Clearance.The Licensee must have LH Livescanned and provide LPA with a Criminal Record Clearance showing LH is eligible in order to continue to provide care.
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 by: Based on observation and interview, the facility did not comply with the section above. The husband of the Licensee, Luis Hernandez (LH), does not have a Criminal Record Clearance which poses an immediate health, safety, or personal rights risk to children in care.
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LPA will conduct a follow up inspection to clear the POC.

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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:Karyn Guerra
LICENSING EVALUATOR NAME:Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
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