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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409084
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:55:27 PM

Document Has Been Signed on 10/14/2021 12:55 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: 7DATE:
10/14/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mayra PulidoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diana Campos arrived the facility at 9:30 am for a POC inspection. LPA entered facility at 9:40 and met with licensee Mayra Pulido. Present during today's inspection were licensee, licensee's fingerprint cleared mother who assists with day care and 7 children in care which consists of 2 infants and 5 preschool age children. The facility was previously cited for the following deficiencies:
-operating outside of licensed capacity and ratio for a small family child care home.
-uncleared adult assistant present in the home.
These deficiencies have been cleared today based on the following observations:
Per LPA's observations and review of records licensee is operating within the licensed capacity today and the uncleared adult who is not present today, has obtained fingerprint clearance and is associated to the facility.
Licensee remains out of compliance of the required ratio for a Small Family Child Care Home. The attached Type A deficiency is being cited today.

Exit interview conducted with the licensee. A Notice of Site Visit was provided and must remain posted for the next 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 10/14/2021 12:55 PM - It Cannot Be Edited


Created By: Diana Campos On 10/14/2021 at 11:14 AM
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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
102416.5(b)(3)(a)

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Staffing Ratio and Capacity
For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time...shall be one of the following:(b) No
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Licensee agrees to adhere to the maximum licensed capacity and ratio for a Small Family Child Care Home. Licensee will submit a written schedule of children in care which will accomodate no more than two infants when more than six children are cared for.
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more than two infants are cared for during any time when more than six children are cared for... At least one child is enrolled and attending kindergarten or elementary school and a second is at least 6 years of age. This requirement was not met as evidenced by: LPA observed 2 infants and 5 preschoolers in care today which poses a risk to health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: PULIDO, MAYRA
FACILITY NUMBER: 073409084
VISIT DATE: 10/14/2021
NARRATIVE
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child is at least six years of age This requirement was not met as evidenced by: LPA observed 2 infants and 6 preschoolers in care today which poses an immediate risk to the health and safety of children in care.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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