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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293617541
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:27:08 PM

Document Has Been Signed on 04/07/2022 12:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ABUNDIZ, ANGELICAFACILITY NUMBER:
293617541
ADMINISTRATOR:ABUNDIZ, ANGELICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 587-1808
CITY:TRUCKEESTATE: CAZIP CODE:
96161
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
04/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Veronica Mallagon - HelperTIME COMPLETED:
01:00 PM
NARRATIVE
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On Thursday, April 7th, 2022, at 9:46am, Licensing Program Analysts (LPA) Blake Morillas and Fabiola Diaz met with Veronica Mallagon, for the purpose of a Case Management Visit. At 9:46am, 7 preschool age children and 8 infants, along with 2 adults were observed.

The purpose of the Case Management visit was to go over a request to add a Co-Licensee as well as to check on the operations at this address since a Change of Location application has been received from the listed Licensee and is currently being processed by the Regional Office. During the visit, LPAs observed the facility not only to be out of ratio, but also over their Licensed Capacity. During conversations with the helpers, it was discovered that the listed Licensee hasn't lived at this address for the past month. Furthermore, the requested individual to be added as a Co-Licensee currently does not live at this address, but noted that they do plan on moving in. LPAs went over the required paperwork to apply for a new license as well as ratio and capacity requirements.

LPA B Morillas and F Diaz informed facility representative Veronica Mallagon that this report dated 4-7-2022 document(s) 3 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA B Morillas and F Diaz informed the facility representative to provide a copy of this licensing report dated 4-7-2022that documents any Type A citation(s) 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 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. Exit interview conducted and report was reviewed with the facility representative Veronica Mallagon.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 04/07/2022 12:27 PM - It Cannot Be Edited


Created By: Blake Morillas On 04/07/2022 at 10:14 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: ABUNDIZ, ANGELICA
FACILITY NUMBER: 293617541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
102416.5(a)

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102416.5(a) Staffing Ratio and Capacity:
The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.
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Facility staff were reminded of the Licensed capacity of the facility and agreed to keep attendance within compliance of Title 22 Regulations.
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Based on observations at the time of arrival, the LPAs observed 15 children in care.
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Type A
04/07/2022
Section Cited
CCR102416.5(d)(1)

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102416.5(d)(1) Staffing Ratio and Capacity: For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home. . ..
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Facility staff were reminded of the ratio requirements of their License and agreed to keep attendance within compliance of Title 22 Regulations.
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 Twelve children, no more than four of whom may be infants. .

Based on observations at the time of arrival, the LPAs observed 8 children under the age of 2 years old.
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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:Keven Peters
LICENSING EVALUATOR NAME:Blake Morillas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 12:27 PM - It Cannot Be Edited


Created By: Blake Morillas On 04/07/2022 at 10:51 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: ABUNDIZ, ANGELICA
FACILITY NUMBER: 293617541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
102370(d)(2)

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102370(d)(2) Criminal Record Clearance: All individuals subject to a criminal record review. . . shall prior to working, residing, or volunteering in a licensed facility. . . Request a transfer of a criminal record clearance. . .
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During the visit, S1 provided the LPAs with the proper forms for a criminal record clearance transfer request. CITATION WILL BE CLEARED ONCE TRANSFER IS MADE BY LPA.
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Based on record review of the fingerprint employee roster for the facility, S1 had been fingerprinted and has obtained a clearance from the department, but was not associated to the facility,
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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:Keven Peters
LICENSING EVALUATOR NAME:Blake Morillas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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