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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233007705
Report Date: 09/18/2023
Date Signed: 09/19/2023 09:51:30 AM

Document Has Been Signed on 09/19/2023 09:51 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:REYNOSO/PALMERIN FAMILY CHILD CARE HOMEFACILITY NUMBER:
233007705
ADMINISTRATOR:REYNOSO, CLAUDIA & PALMERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 463-8468
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Osvaldo PalmerinTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Leticia Rosales conducted a case management inspection at the facility and met with Licensee, Osvaldo Palmerin. The purpose of the inspection is to cite for the licensees not providing parents with copies of the Family Child Care Home (FCCH) Addendum to Notification of Parents’ Rights form LIC 995B form, regarding Removal/Exclusion of Adult 1 (A1) dated 8/18/23, by the next business day or the next day the children are in care. Interviews corroborate that licensees had Parent 3 (P3) and Parent 8 (P8) sign the Family Child Care Home (FCCH) Addendum to Notification of Parents’ Rights form LIC 995B form without providing the parents with the 8/18/23 LIC 995B form.

Title 22 deficiency is being cited on the attached LIC 809D and civil penalties are being issued. Appeal rights were provided. Exit interview conducted, and report was reviewed with Licensee, Osvaldo Palmerin.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA Rosales informed Licensee, Osvaldo Palmerin that this report dated 9/18/23 documents one Type A citation which shall be posted for 30 consecutive days. LPA Rosales informed Licensee, Osvaldo Palmerin to provide a copy of this licensing report dated 9/18/23 that documents one Type A citation 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. An Acknowledgement of Receipt of Licensing Reports LIC 9224 form must be completed and signed by each parent/guardian and placed in each child's file for verification.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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Document Has Been Signed on 09/19/2023 09:51 AM - It Cannot Be Edited


Created By: Leticia Rosales On 09/18/2023 at 11:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REYNOSO/PALMERIN FAMILY CHILD CARE HOME
FACILITY NUMBER: 233007705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2023
Section Cited
CCR
102370.1(b)(2)

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Criminal Record Exemptions:
In addition to the requirements of Section 102370.1(a), the licensee must: (2) Provide a copy of the Addendum to Notification of Parent's Rights (Regarding Removal/Exclusion) to one parent or authorized representative of every child currently in care within one day of receipt of the addendum from the Department.
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Licensee stated we did call all the parents to come and sign the form LIC 995B, and the majority did come, but some parents did not. And the ones who came were provided with the form LIC 995B.
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This requirement is not met as evidenced by: Licensees did not provide Parent 3 (P3) and Parent 8 (P8) with Addendum to Notification of Parents’ Rights form LIC 995B form dated 8/18/23.
A $200.00 is being assessed.
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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:Alexis Hollon
LICENSING EVALUATOR NAME:Leticia Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023


LIC809 (FAS) - (06/04)
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