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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910105
Report Date: 12/08/2025
Date Signed: 12/08/2025 11:42:08 AM

Document Has Been Signed on 12/08/2025 11:42 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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:DIAZ, CLEMENTINA FAMILY CHILD CAREFACILITY NUMBER:
543910105
ADMINISTRATOR/
DIRECTOR:		DIAZ, CLEMENTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 690-4687
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
12/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Clementina DiazTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 12/08/2025, Licensing Program Analyst (LPA) Christopher Burnias and Licensing Program Manager (LPM) Luisa Gavoutian went to the facility to follow up on an unusual incident that was reported to the Department on 10/03/2025.

Licensee had reported to the Department that an incident occurred on 10/02/2025 where Child 1 (C1) had been playing on a free standing punching bag that was in the play area of the front yard of the facility and fell off the punching bag resulting in an injury to their left arm.

Licensee reported that they, along with Staff 1 (S1) observed the incident occur, tended to the child once they injured themselves, and contacted C1’s parent to inform them of the incident. C1 was picked up from care and received medical attention.

Information obtained through interviews and record review indicate that C1 climbed on top of the free-standing punching bag, attempted to sit on top of the punching bag, positioned themselves on their stomach on top of the punching bag, then fell to the ground. It has been determined by medical staff that C1 sustained a broken left arm due to the fall.

The Department has determined that Licensee violated C1’s personal rights by not providing a safe environment for the children. Licensee did not prevent the inappropriate use of the equipment, which resulted in C1 sustaining a serious injury.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiency is being cited: (see next page).

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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 4
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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: DIAZ, CLEMENTINA FAMILY CHILD CARE
FACILITY NUMBER: 543910105
VISIT DATE: 12/08/2025
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Licensee was provided appeal rights.

LPA Burnias informed licensee Clementina Diaz that this report dated 12/08/2025 documents one Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Burnias informed the licensee to provide a copy of this licensing report dated 12/08/2025 that documents any Type A citations 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 Acknowledgement of Receipt of Licensing Reports was given to Licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2025 11:42 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Christopher Burnias On 12/08/2025 at 08:18 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: DIAZ, CLEMENTINA FAMILY CHILD CARE
FACILITY NUMBER: 543910105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/09/2025
Section Cited
CCR
102423(a)(2)

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Personal Rights (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged. These rights include… (2) To receive safe... accommodations, furnishings, and equipment. This requirement was not met as evidenced by:
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Licensee has removed the punching bag and made it inaccessible to children. Licensee stated they will provide a written statement to the Department on their plan to ensure that children are provided with age appropriate toys, furnishings, play equipment
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Based on interviews and record review, Licensee did not comply with the section cited above. Licensee did not prevent inappropriate use of equipment which resulted in C1 breaking their arm which posed an immediate health, safety or personal rights risk to persons in care.
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and how they will ensure that children use equipment appropriately according to manufacturer’s recommendations.

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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.
Luisa Gavoutian
NAME OF LICENSING PROGRAM MANAGER:
Christopher Burnias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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