Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618282
Report Date: 11/08/2019
Date Signed: 11/08/2019 02:50:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MARIN, MARIA ELENAFACILITY NUMBER:
343618282
ADMINISTRATOR:MARIN, MARIA ELENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 834-1492
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:14CENSUS: 7DATE:
11/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Maria MarinTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mai Lor and Christopher Bello conducted an unannounced inspection at the above facility to follow up on an unusual incident report received by the Sacramento Regional Office on 11/4/19. Upon arrival LPAs met with Licensee's adult daughter acting as an assistant Denisse Marin. LPAs observed seven children in care, one under the age of two. LPAs observed two children on the trampoline without adult supervision. The assistant was inside the facility with five children. Shortly after, two more children were observed on the trampoline. According to manufactured guidelines, adult supervision is required at all times and no more than one person on the trampoline at a time. This is considered an immediate health and safety risk to children in care. LPAs observed the stairs not barricaded when there are children present under the age of five, which poses an immediate health and safety risk to children in care. Approximately 30 minutes of LPA's arrival, Licensee Maria arrived on site.

LPAs conducted interviews with children and assistant.

Title 22 Regulations cited on the subsequent LIC 809.

Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D 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. LIC 9224 and Appeal Rights were provided.

Exit interview conducted a notice of site visit was provided and posted.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: MARIN, MARIA ELENA
FACILITY NUMBER: 343618282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2019
Section Cited

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The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to...This requirement was not met as evidenced by:
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Based on observation, LPAs obseved four children on the trampoline at once without adult supervison, which poses an immediate health and safety risk to children in care.
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Type A
11/11/2019
Section Cited

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Where children less than five years old are in care, stairs shall be fenced or barricaded. This requirment was not met as evidenced by: Based observation, LPAs observed

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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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2019
LIC809 (FAS) - (06/04)
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