Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503605760
Report Date: 11/03/2017
Date Signed: 11/03/2017 03:13:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:BELTRAN, EVAFACILITY NUMBER:
503605760
ADMINISTRATOR:BELTRAN, EVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 545-2127
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:14CENSUS: 2DATE:
11/03/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Eva BeltranTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An annual visit #2 is being conducted by LPA Claudia Henley. I was met by licensee Ms. Beltran. There were two children present today. A tour of the home, inside and outside, as shown on the facility sketch is provided. This home is a two story home, and children do not have access to the second story. There was an installed child proof gate at the foot of the stairs. There are no firearms in this home, per licensee. No bodies of water on the premises. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. Fire/disaster drill conducted in June of 2017. Fireplace is not used during day care. There is a working fire extinguisher, a smoke detector, carbon monoxide detector and there is adequate heating and ventilation for safety and comfort. Safe toys and play equipment are observed. There is a working telephone. Adequate supervision is being provided during this visit. Children are supervised when outside in the fenced play area. There are two storage sheds that are locked. There is one dog on the premises that is inaccessible to the children and stays upstairs while children are parent. Capacity as specified on the license is being maintained. Staff-child ratios are maintained. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Pediatric CPR & Pediatric First/Aid is current on licensee. No medication is given to day care children. Two children's files were reviewed. Licensee stated she has had her immunization, but was not able to provide a copy of the record today.

The child care hours/days of operation are: Monday through Friday, 7:00 a.m. to 5:30 p.m.
The following is cited per Title 22 Regulations (see page 2). Appeal Rights left with licensee. Site Visit Notice posted on the parent board.

Incidental Medical Services (IMS) was discussed.. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: BELTRAN, EVA
FACILITY NUMBER: 503605760
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2017
Section Cited
HSC
1597.622
1
2
3
4
5
6
7
Health & Safety Code - Section 1597.622: The Licensee to have appropriate records for immunizations (Influenza, Pertussis & Measles). Licensee stated that she had the immunizations, but did not have records available for review today.
1
2
3
4
5
6
7
Licensee to send a copy of the immunization record to CCL by 12/4/17 to avoid a civil penalty in the future for failure to submit the record by due date above
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Valarie ReedTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2