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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153808615
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:15:45 PM

Document Has Been Signed on 09/11/2023 04:15 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:TIERRA SERENA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
153808615
ADMINISTRATOR:LORENA PALOMOFACILITY TYPE:
850
ADDRESS:17213 CENTRAL VALLEY HWYTELEPHONE:
(661) 746-0671
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
09/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lorraine PalomoTIME COMPLETED:
04:45 PM
NARRATIVE
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On 09/11/2023, Licensing Program Analyst (LPA) Ocegueda conducted a case management inspection to address reporting requirements. LPA met with Center Director Lorraine Palomo today and informed her of the reason for the inspection. LPA toured the facility, and a census was taken. There were no children present today due to early release.

Today, LPA addressed an incident that was confirmed through multiple interviews to have occurred at the facility on 8/14/2023. The incident involved child#1 being mistakenly released by staff #1 to an unrelated authorized representative (Adult #1). Adult #1 is a relative of and is listed on the emergency identification card as an adult who is authorized to pick up a different child (child #2) from the facility. Multiple interviews revealed that adult #1 walked outside of the building and walked back in after realizing he/she picked up the wrong child (see 9099 report dated 9/11/2023 for further details). The facility staff did not follow the reporting requirements for this incident as it was not reported to the Licensing Department as required by the regulation.

Today, LPA Ocegueda discussed reporting requirements in detail. LPA informed Center Director Palomo that any possible staff misconduct where regulations were not or might not have been adhered to should be reported to the Department. Internal facility investigations do not take the place of the Departments reporting requirements or inspections from the Department to address incidents. LPA advised that if facility representatives are not sure if something should be reported as an unusual incident, Licensing Department representatives are available for consultation.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Ruby Ocegueda
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: TIERRA SERENA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 153808615
VISIT DATE: 09/11/2023
NARRATIVE
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Today, LPA Ocegueda reviewed the following regulation and reporting requirements in detail:

Reporting Requirements CCR 101212(d)(1)(C)

(d) Upon the occurrence, during the operation of the childcare center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

Per the California Code of Regulations (CCR) Title 22, Division 12, Chapter 1 of the following deficiency is being cited (see 809-D). Appeal Rights were provided.

Today, LPA Ocegueda conducted an exit interview with Site Supervisor Lorraine Palomo. LIC 9213 Notice of Site Visit should be posted for 30 days.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Ruby Ocegueda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2023 04:15 PM - It Cannot Be Edited


Created By: Ruby Ocegueda On 09/11/2023 at 02:21 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: TIERRA SERENA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 153808615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2023
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements. Upon the occurrence, during the operation of the childcare center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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Facility representatives will provide the Department with signed statement indicating their understanding of reporting requirements.In addition an Unusual Incident Report LIC 624 will be provided to the Deparment. Proof will be submitted to the Department by POC date: 9/25/2023.
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(C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.This requirement was not met as evidenced by: record review and interviews. Facility representatives did not report child#1 being released to an unauthorized representative on 8/14/2023. This poses a potential risk to the health, safety and or personal rights risks to children in care.
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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:Susie Fanning
LICENSING EVALUATOR NAME:Ruby Ocegueda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
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