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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622553
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:06:57 PM

Document Has Been Signed on 09/15/2025 02:06 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REVELES-MEDINA, MARIAFACILITY NUMBER:
343622553
ADMINISTRATOR/
DIRECTOR:		REVELES-MEDINA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 623-5574
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
09/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Maria Reveles MedinaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 09/15/2027, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Maria Reveles Medina (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. Also present in the FCCH was L1’s 2 adult Aides. LPA observed 8 preschool aged children being supervised by L1 and both Aides. LPA accessed Guardian to determine that all required adults were background cleared and associated to the license. L1 stated that there are no new residents in the home since licensure and confirmed that there are no Registered Sex Offenders living in the facility. LPA completed the RSO profile on 09/12/2025. LPA assessed that annual fees are not current and notified L1.

LPA toured the areas of the FCCH that are accessible to children in care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include Building A and back yard, Salon Building, shed (Building B backyard), chicken coop, spa, tree house, garden shed, shop, dog kennel, and back lot. The ON-limits areas of the FCCH are Building B and backyard/playground and the front yard of Building A. L1 acknowledged that children may never enter the OFF-limits areas. L1 reports her hours of operation to be 7 days per week for 23 hours per day.

LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA reviewed the children’s files for those who were in attendance. LPA reviewed the adult’s files and immunizations. LPA reviewed the Facility’s Roster and observed the Fire Drill log to ensure that drills are conducted at least once every 6 months. Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REVELES-MEDINA, MARIA
FACILITY NUMBER: 343622553
VISIT DATE: 09/15/2025
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A functioning dual smoke and carbon monoxide detector was tested. LPA observed cleaners and detergents stored in cabinets that are behind doors with child safety locks. LPA observed a knife on top of the kitchen refrigerator. LPA observed a 2A10BC fire extinguisher that appeared to have a reading in the green zone. L1 stated that the first-aid kit is stored near the main entrance. Toys appeared to be safe and in good supply. LPA inspected a spa with a hard top cover which was equipped with 4 locks. The spa is located in the OFF-limits back yard of Building A. LPA walked the perimeter of the backyard in Building B and ensured the stability of the surrounding fence. LPA observed a play structure in the back yard that appeared to be in working condition and was cushioned by wood chips. L1 stated there are no firearms in the FCCH and she does not own any pet(s).

LPA discussed Mandated Reporter Training with L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. L1 has a current Mandated Reporter Training Certificate which will expire on 10/2025. Current Pediatric CPR and First Aid training was also verified by LPA and will expire on 08/2026.

LPA discussed the Safe Sleep Regulations with L1 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. LPA also informed L1 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 that s/he register all infant devices with the CPSC to be notified of any recalls on purchased equipment.

Incidental Medical Services (IMS) policy was discussed with L1, and LPA provided the IMS guidelines. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/. Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 02:06 PM - It Cannot Be Edited


Created By: Katy Velazquez On 09/15/2025 at 01:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REVELES-MEDINA, MARIA
FACILITY NUMBER: 343622553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 comply with the section cited above when an adult Aide's file was missing proof of TB and MMR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Proof of MMR and TB for Aide Angelica Savala will me emailed to LPA by 5:00 PM on 10/15/2025.
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.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REVELES-MEDINA, MARIA
FACILITY NUMBER: 343622553
VISIT DATE: 09/15/2025
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information through this communication platform. To receive important licensed related information, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

L1 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours per day. L1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. L1 understands that if any structural changes are made to the FCCH; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years.



A Type B deficiency was cited on subsequent 809-D page(s). An exit interview was conducted, and the report was reviewed with Licensee Reveles Medina. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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