Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203904885
Report Date: 09/23/2015 12:00:00 AM
Date Signed: 09/23/2015 12:54:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:BECERRA, GUADALUPE FAMILY CHILD CAREFACILITY NUMBER:
203904885
ADMINISTRATOR:BECERRA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 675-3809
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY:14CENSUS: 0DATE:
09/23/2015
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee, Guadalupe BecerraTIME COMPLETED:
01:10 PM
NARRATIVE
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On this date LPA Kathie Campbell conducted an unannounced Case Management visit. Met with licensee, her friend, grandson and his friend. Licensee's friend translated during this visit. The purpose of this visit it to ensure an excluded individual is not living in the home. LPA presented licensee with the Decision and Order. A tour of the home was made. There were no children present during this visit. Licensee stated she is only taking care of children in the morning before school. LPA gave licensee copies of livescan request forms.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found: (see LIC809-D) Exit interview was conducted with licensee, Guadalupe Becerra


Site Visit Notice posted on the parent board.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)243-4588
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2015
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME: BECERRA, GUADALUPE FAMILY CHILD CARE
FACILITY NUMBER: 203904885
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2015
Section Cited
102370(d)(1)
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102370(d)(1) Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the
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Licensee's friend called livescan during this visit to schedule an appointment. Ms. Ordaz stated she will move out of the home until she gets a fingerprint clearance. Licensee to send in statement of understanding regulations regarding
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Department. Licensee's friend Martha Ordaz stated she is living in the home until she finds an apartment. Ms. Odaz stated she has only been living at the residence for one day. This is an immediate Civil Penalty of $100.00 a day for a maximum of 5 days.
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fingerprint clearances for individuals residing in the home or caring for children. To be received at the Fresno CCL Office on or before 9/28/25.
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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: Duane MatsubaraTELEPHONE: (559)243-4588
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2015
LIC809 (FAS) - (06/04)
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