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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103900956
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:52:58 PM

Document Has Been Signed on 08/25/2022 12:52 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:ALVAREZ,AMALIAFACILITY NUMBER:
103900956
ADMINISTRATOR:ALVAREZ,AMALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 399-3046
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Amalia AlvarezTIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/25/22 Licensing Program Analyst, (LPA) Caroline Harris and Licensing Program Manager (LPM) Juvenal Moctezuma conducted an unannounced annual inspection. LPA's met with Licensee, Amalia Alvarez. Also present was her daughter/assistant, who helped interpret and another unfingerprinted assistant. LPAs conducted a tour of the home, inside and outside, as shown on the facility sketches (LIC 999A) provided. LPA's observed all required licensing forms to be posted in a visible location for authorized representatives to view them. A census was taken and there were six day care children present. The licensee has two dogs that are kept in the back yard and off limits room, away from the day care children. The licensee is aware of the safety of children around animals and takes responsibility for any action taken by her pets. The LPA observed inaccessible rooms to be off limits to children by the use of baby gates and locks. The accessible rooms were the day care room, living room, dinning room, kitchen and bathroom. The outdoor play area in the back yard is fenced. Licensee is aware that children are to be supervised when outside an unfenced play area. There are no swimming pools or other bodies of water on the premises. The LPA observed safe toys and play equipment both indoors and outside. There were no poisons observed on the premises accessible to children. Licensee is aware that poisons are required to be locked and inaccessible to children. Cleaning compounds, medications and other hazardous items are to be inaccessible to children. During the inspection, the LPA's observed some keep out of reach items that were accessible to children. There are no firearms or ammunition present at this facility. Fireplace is inaccessible to children during day care hours. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. The licensee has a complete first aid kit, including bandages, scissor, thermometer, gloves and a first aid manual. There are no stairs in the home. There is a working telephone and the above telephone number was verified.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Caroline Harris
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 10
Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Upon arrival, the LPA's observed an infant 0-12 months old, sleeping in a swing, with a blanket on them. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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The licensee was told to immediately take the infant out of the swing and place them in the pack and play. LPA's went over safe sleep requirements with the licensee and her assistant, which the licensee had previously been given information on the regulations.
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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One of the licensee's assistants, who lives in the home, has a pending fingerprint clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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The licensee agrees to re-take the family child care orientation. Licensee understands that any adults living or helping during day care hours, must be fully cleared and associated to the day care license, prior to having contact with children in care. Helper #3 left the facility.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


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Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Upon inspection, the LPA's observed drawers in the kitchen that contained sharpie markers, pointed scissors, nail clippers and tools that were accessible to children. Under the kitchen sink, one of the baby latches did not work, making dishwasher pods accessible. In the laundry room, detergent, bleach and cleaning supplies were on shelves that were low and accessible to children. Also, a case of Guinness beer was on the floor. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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The licensee's assistant removed the keep out of reach items and placed them out of reach.
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the LPA's observed that the licensee did not have tight fitted sheets for the mattress in the cribs. Instead, the licensee had a blanket that was wrapped around the pad. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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The licensee took the blanket out of the crib and will purchase tight fitting sheets for the pack and play.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


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Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reveiew the licensee did not have files for her assistants with required documentation. The licensee also did not have all required documents for herself. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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The licensee agress to have complete files for herself and staff by the due date of 8/9/22.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have proof of her MMR. The licensee's assistants also did not have proof of MMR, T Dap or influenza. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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The licensee agrees to have all required immunizations for her helpers available for review by the due date of 8/9/22.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have proof of immunizations for all of the children's files and they were not transcribed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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The licensee agrees to get copies of children's immunizations and transcribe them on to blue cards by the due date of 9/8/22. A return visit will take place in order to clear this deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, three of the children's file did not have signed receipts for parent rights. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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The licensee agrees to get all parents to sign the LIC 995A, Parents Rights form and have it available for review by the due date of 9/8/22.

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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 08/25/2022 12:52 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/25/2022 at 11:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the infant in care 0-12 months, did not have an individual sleep plan in the file. The licensee also did not have the 15 min checks documented for infants 0-24 months. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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The licensee previously had the licensing forms in a file. The licensee agrees to immediately start logging the 15 min check and have the parent complete the individual sleep plan.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


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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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956
VISIT DATE: 08/25/2022
NARRATIVE
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Adequate supervision is being provided during this visit. Capacity as specified on the license is being maintained. LPA reviewed six children’s files. Not all required licensing documents were observed in each of the children’s files, including a copy of the Family Child Care Home Notification of Parent's Rights (LIC 995A). Licensee also did not maintain documentation of immunizations for all children. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Fire drills are conducted and documented with the date, time and how many children present, every six months. Licensee is aware that children are never to be left in parked vehicles. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. One of the licensee's assistants, who lives in the home, has a pending fingerprint clearance. 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. 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. Pediatric CPR/First Aid are current and expire on 10/2/23. The licensee did not maintain all required documentation of immunizations against pertussis, measles and influenza for herself and staff. Days and hours of operation are Monday – Friday; 6:30 AM – 6:30 PM.

An exit interview was conducted with the Licensee. LPA reviewed with licensee the Mandated Child Abuse Reporter Training (AB 1207), which the licensee completed on 1/10/22. It is required to be updated every two years. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Caroline Harris
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956
VISIT DATE: 08/25/2022
NARRATIVE
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LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider is to physically check on sleeping infants (0-24 months) every fifteen minutes and document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. The licensee was not documenting the 15 minute checks. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan was not completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. Information on Lead Poisoning was also provided to the licensee and she was informed that the information is required to be posted on the parent board. The LPA and licensee discussed the Community Care Licensing website: www.ccld.ca.gov. which provides access to Provider Information Notifications (PINS), Quarterly Updates that inform licensees of new legislation and regulations, training's, and Licensing forms and updated information. The licensee was also advised that it is her responsibility to stay current with regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are found (see next page): 809 D. LPA, Harris informed licensee that this report dated (8/25/22) document(s) (2 type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Also, LPA, Harris informed the licensee to provide a copy of this licensing report dated (8/25/22) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Caroline Harris
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: ALVAREZ,AMALIA
FACILITY NUMBER: 103900956
VISIT DATE: 08/25/2022
NARRATIVE
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An exit interview was conducted and a copy of this report, along with appeal rights was provided to the licensee, Amalia Alvarez and was reviewed with the licensee and her daughter. This report shall be made available to the public upon request. The LIC 9213 Notice of Site Visit form was provided to the licensee and must remain posted for 30 days.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Caroline Harris
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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