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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409084
Report Date: 10/07/2021
Date Signed: 10/07/2021 06:54:28 PM

Document Has Been Signed on 10/07/2021 06:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PULIDO, MAYRAFACILITY NUMBER:
073409084
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 9DATE:
10/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:09 PM
MET WITH:Mayra PulidoTIME COMPLETED:
07:15 PM
NARRATIVE
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At 1:05 pm on 10/07/21, Licensing Program Analyst (LPA) Diana Campos conducted a case management inspection as a result of a complaint investigation. Upon arrival LPA rang the doorbell licensee's fingerprint-cleared mother who assists with the day care answered the door. LPA asked the assistant if the licensee was present and answered that she was not at the facility but was arriving soon. At 1:15pm approximately LPA observed a female adult present in the kitchen, 4 children sleeping in the living room 3 children sleeping in the bedroom to the right of hallway and one infant who was sleeping in the bedroom to the left of the hallway who was picked up by the female adult assistant who was present during LPA's arrival. Assistant that picked up the infant from one of the bedrooms was not associated to the facility and does not have fingerprint clearance.

Around 1:20 pm, LPA toured the entire home with the licensee's mother. Around 1:30 pm the licensee Mayra Pulido arrived at the home. LPA requested the facility roster, licensee did not have a roster available for LPA to review and created one while LPA reviewed 9 children's files. Per licensee, the adult female who was present upon LPA's arrival is only there to clean the home.

See 809-D for one Type A deficiency and one Type B deficiency cited today.

Exit interview conducted with licensee. This report shall remain on file for 3 years.
Report and Appeal Rights were provided to licensee
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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 10/07/2021 06:54 PM - It Cannot Be Edited


Created By: Diana Campos On 10/07/2021 at 05:37 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: PULIDO, MAYRA
FACILITY NUMBER: 073409084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
102416(d)(1)

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Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance or a criminal record exemption as required by law or Department regulations...
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Assistant left during today's inspection. Per licensee this individual only assists with the cleaning and will not be in the pressence of children in care until she is fingerprinted and associated to the facility.
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Request a transfer of a criminal record clearance as specified in Section 102370... This requirement was not met as evidenced by, adult present in the home was not associated to the facility and per licensee did not have a criminal record clearance. This poses a risk to the health and safety of children in care.
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Type B
10/08/2021
Section Cited
CCR102417(8)

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Operation of a Family Child Care home.
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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Licensee created a children's roster and provided a copy to LPA during today's inspection. Going forward licensee will continue to keep a current copy of her children's roster available at all times.
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This requirement was not met as evidenced by: Licensee did not have a roster readily available to LPA for review today.
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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021


LIC809 (FAS) - (06/04)
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