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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393611423
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:17:16 AM

Document Has Been Signed on 09/01/2021 11:17 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MORA, AMYFACILITY NUMBER:
393611423
ADMINISTRATOR:MORA,AMYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 430-6184
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
09/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Amy MoraTIME COMPLETED:
11:30 AM
NARRATIVE
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On 09/01/21 at 9:50 AM LPA Jackson arrived at the home day care for Amy Mora. LPA observed the assistant arrive at 9:57 am. LPA conducted a tour of the home and observed 12 children in care. Licensee stated that her assistant had left for just a moment to go home and get their phone. This left the licensee home alone with 12 children in care. Based on the observations, a citation is being assessed to the home day care for operating without an assistant present.

Title 22 Deficiencies have been cited on the subsequent 809-D page of this report and Notice of Site Visit and appeal rights provided.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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 09/01/2021 11:17 AM - It Cannot Be Edited


Created By: Christopher Jackson On 09/01/2021 at 10:46 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MORA, AMY
FACILITY NUMBER: 393611423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2021
Section Cited
CCR
102416.5(e)

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Upon arrival LPA observed the assistant arrive at the home after the LPA. LPA observed 12 children in care. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small
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Licensee's assistant arrived at the home placing the facility into compliance. In addition licensee inquired about adding a family member to the association list, to utilize in case of emergency staffing issues.
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Family Child Care Home as specified in subsections (b) and (c). This poses an immediate health and safety risk 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:Justin L Denton
LICENSING EVALUATOR NAME:Christopher Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
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