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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620805
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:39:05 PM

Document Has Been Signed on 05/24/2023 03:39 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:AGUILERA, MARIAFACILITY NUMBER:
343620805
ADMINISTRATOR:A., MARIA & V., JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 308-9084
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
05/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Assistant Jessica Vazquez TIME COMPLETED:
04:00 PM
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On 5/24/23, Licensing Program Analyst (LPA) Carla Polanco met with Assistant Jessica Vazquez (A1), to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 5/22/23. The facility reported the UIR to Community Care Licensing within 24 hrs. A written UIR was submitted within 7 days, describing the specifics of the incident. During today's visit the facility was toured. Present were 12 children and two qualified adult assistants.

LPA interviewed individual 1, who was present during the incident and A1. A1 stated that on 5/22/23 at approximately 10:30 AM a child in care wandered away from the Family Child Care Home unsupervised. A1 stated that she left the child with individual 1, while she conducted school drop offs. A1 stated that the child was found by a City of Galt Police Officer who was in the area. A1 stated that the child was safe and did not need medical attention. A1 states that the child's family was promptly notified of the incident.

LPA conducted an observation of the neighborhood. Upon inspection, LPA saw where the child was found at the corner of the street, eight houses away from the facility. LPA reviewed the facility's files and collected pertinent documentation.

LPA informed Assistant Jessica Vazquez, that this report dated May 24, 2023, documents two Type A citations, which is an immediate Health and Safety, or Personal Rights risk to persons in care. A separate 809-D page was issued for the deficiencies. LPA and A1 discussed the assessment of civil penalties. LPA informed Licensee, that this report dated May 24, 2023, will also document and assess a civil penalty, due to a child being left unattended; or left alone with a person under 18 years of age; or lack of supervision resulting in a child wandering away.

An exit interview was conducted, and the report was reviewed with the Assistant Jessica Vazquez. LPA posted a notice of site visit. Licensee understands the notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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 05/24/2023 03:39 PM - It Cannot Be Edited


Created By: Carla Polanco Rivera On 05/24/2023 at 02:38 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: AGUILERA, MARIA
FACILITY NUMBER: 343620805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
102417(a)

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102417 Operation of a Family Child Care Home. (a) the licensee shall be present... and shall ensure that children in care are supervised at all times. This requirement was not met by evidenced by:
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Assistant stated she will keep 100% supervision of child and ensure child is unable to have acess to the door by keeping a baby gate in the living room area.
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Based on interviews conducted, it was determined a child wandered away from the facility, and turned the corner of the licensee's street, to the cross street, and located by a police officer. This is an immediate health and safety risk to children in care.
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IMMEDIATE CIVIL PENALTY IN THE AMOUNT OF $500 IS ASSESSED
Type A
05/25/2023
Section Cited
CCR102417(a)

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102417 Operation of a Family Child Care Home. (a) the licensee shall be present... children in care are supervised at all times....the licensee to be temporarily absent...for a substitute adult to care...the children during his/her absence. This requirement was not met as evidenced by:
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Assistant stated she will not leave children in care with any person under 18 years of age and will only leave children in care with another fully qualified assistant.
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Upon self-report, it was revealed the Assistant was not present in the home when daycare child was in care. LPA was made aware that a minor was left in charge of daycare child. 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:Jeanne Smith
LICENSING EVALUATOR NAME:Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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