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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573607570
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:31:54 AM

Document Has Been Signed on 02/14/2024 10:31 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LARA, GUADALUPEFACILITY NUMBER:
573607570
ADMINISTRATOR:LARA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 574-0121
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:licensee, Guadalupe LaraTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Lauren Scott and Carla Polanco Rivera met with licensee, Guadalupe for the purpose of a case management inspection due to deficiencies. LPAs also cleared deficiencies cited from 12/28/2023.

Upon arrival for the complaint investigation on 12/28/24, LPAs were made aware of an adult living in the home who was not reported to CCLD. Follow up interviews conducted also revealed that Licensee also gave false information regarding the presence of her daughter in the home, without criminal record clearance or exemption.

LPA Scott informed licensee that this report dated February 14, 2024, documents one Type B citation, stating there is a potential risk to the health, safety, or personal rights of children in care. This report also documents one Type A citation, stating there is an immediate risk to the health, safety or personal rights of children in care.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.

Upon receipt of Type A citations, the licensee shall post and provide copies of the LIC 9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 9099-D in each child's file.



An exit interview conducted, and report was reviewed with the licensee, Guadalupe Lara. Appeal of Rights were provided. 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 $100.00.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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 02/14/2024 10:31 AM - It Cannot Be Edited


Created By: Lauren Scott On 02/14/2024 at 09:52 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LARA, GUADALUPE
FACILITY NUMBER: 573607570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2024
Section Cited
CCR
102402(a)(3)

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Conduct in the operation or maintenance of a family day care home which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility...
This requirement was not met as evidenced by:
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Licensee provided written statement during inspection conducted on 12/28/2023.The Licensee’s spouse has obtained criminal record clearance or exemption. The department is seeking further guidance from the legal division
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Based on interviews, it was revealed the licensee’s daughter has been in the home during operating hours and husband has been living in the home, both without a criminal record clearances or exemptions. Licensee gave false statements regarding the presence of their daughter in the home
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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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2024 10:31 AM - It Cannot Be Edited


Created By: Lauren Scott On 02/14/2024 at 10:01 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LARA, GUADALUPE
FACILITY NUMBER: 573607570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
102416.2(a)(2)

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(a)The licensee shall report... within the Department's next business day and during normal working hours (8am to 5pm). (2) any change in household composition including adults moving in…
This requirement was not met as evidenced by:
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Licensee will complete an updated LIC279 and submit to the department by POC date
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Based on interviews conducted, it was revealed that licensee is married and her husband has been living in the home for the past 5 years without a reported change of household composition to CCLD.
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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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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