Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503908292
Report Date: 04/20/2017
Date Signed: 04/20/2017 03:05:16 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:MARTINEZ, DIANNA FAMILY CHILD CAREFACILITY NUMBER:
503908292
ADMINISTRATOR:MARTINEZ, DIANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 380-4059
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY:14CENSUS: 9DATE:
04/20/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dianna MartinezTIME COMPLETED:
03:30 PM
NARRATIVE
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(3) Licensing Program Analysts (LPAs) Catherine Chambers & Claudia Henley conducted an unannounced annual/random visit. LPAs met with Licensee Dianna Martinez, Also present was minor assistant and 9 children in care. LPAs conducted a tour of the home, inside and outside, as shown on the facility sketches (LIC 999 & 999A) provided. No pets are observed at today's visit. There are no "bodies of water" or firearms in this home. There are no poisons on the premises. Cleaning compounds, medications and other hazardous items are inaccessible to children. The fireplace is inaccessible to children. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. There is a working telephone and number was verified. Adequate supervision is being provided during this visit. Capacity as specified on the license is being maintained. Licensee has a current roster of the children. Licensee is required to maintain documentation of immunizations for the children. LPA discussed Incidental Medical Services (IMS) and left the Plan for Providing Incidental Medical Services (IMS) – FCCH Requirements.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: Rebecca VarelaTELEPHONE: (559) 650-7856
LICENSING EVALUATOR NAME: Catherine ChambersTELEPHONE: (559) 341-4450
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2017
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 3


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: MARTINEZ, DIANNA FAMILY CHILD CARE
FACILITY NUMBER: 503908292
VISIT DATE: 04/20/2017
NARRATIVE
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Licensee has provided parents with a copy of the Family Child Care Home Notification of Parent's Rights (LIC 995A). Fire drills are conducted and documented with the date and time every six months Licensee is aware that children are never to be left in parked vehicles. 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. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care. Pediatric CPR/First Aid are current and expire 1/24/18. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice.

LPA & licensee discussed the Community Care Licensing website: www.ccld.ca.gov. LPA and licensee discussed new additions to the website that include the new PIN (Provider Information Notification) and information for providers including the Quarterly Update that informs licensees of new legislation and regulations. LPA left a copy of A Child Care Provider’s Guide to Safe Sleep

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are found


(see next page):


THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Rebecca VarelaTELEPHONE: (559) 650-7856
LICENSING EVALUATOR NAME: Catherine ChambersTELEPHONE: (559) 341-4450
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: MARTINEZ, DIANNA FAMILY CHILD CARE
FACILITY NUMBER: 503908292
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2017
Section Cited
102421(a)
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Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice. Licensee was unable to provide complete child records. The only forms that the licensee maintains is the roster and an emergency contact sheet. Licensee was sited for this deficiency at the time of the last
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Licensee shall notify LPA that the children's files have been compiled. LPA will return to confirm that each child in care has a file and that each file contains all required documentation. This must be completed by April 27, 2017.
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visit and was given a date for the files to be completed. Licensee confirmed by telephone that she had complete files for children in care. At the time of this visit, licensee stated that she did not know that forms for each child were required. This may pose a risk to children in care.
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Type B
04/27/2017
Section Cited
102418 (g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. Licensee does not have proof of current immunization records for children in care. This may pose a risk to children in care.
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Licensee shall compile and maintain immunization records for all children in care.
Type B
04/27/2017
Section Cited
H&S 1597.622(c)
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The family day care home shall maintain documentation of the required immunizations or exemptions from immunization During the visit the licensee was unable to provide proof of measles and pertussis immunizations. Failure to obtain the proper immunization presents a potential risk to the children.
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Licensee shall submit proof of Measles, Whooping Cough, and Influenza by April 27, 2017.
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: Rebecca VarelaTELEPHONE: (559) 650-7856
LICENSING EVALUATOR NAME: Catherine ChambersTELEPHONE: (559) 341-4450
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3