<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393619809
Report Date: 09/29/2026
Date Signed: 09/29/2026 04:06:04 PM

Document Has Been Signed on 09/29/2026 04:06 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HERNANDEZ, ELVIAFACILITY NUMBER:
393619809
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, ELVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 426-6244
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 14TOTAL ENROLLED CHILDREN: 29CENSUS: 9DATE:
09/29/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Ma.Elena Cervantes AndredeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Corina Beckby and Elizabeth Santiago conducted an unannounced field visit to the facility. LPA arrived at the facility and was met by assistant Ma.Elena Cervantes Andrade. Assistants are Spanish speaking providers and the report is translated in English. Present were 3 assistants (Ma.Elena Cervantes Andrade, Anthony Hernandez and Francisco Oregel Cervantes, supervising 9 children including 2 infants (ages unknown). Adult daughters Daisy Hernandez and Jennifer Hernandez arrived during the visit. Adult son, Juan was also present in the home. Licensee was not home.

Upon entering the living room, LPA Beckby observed that it was naptime. LPA observed an infant sleeping in a bouncer with a blanket. Assistants did not have a current sleep log for the 2 infants in care. Assistants showed old sleep logs with the same sleep times and wake up times for all infants. LPA Beckby observed the infant climbing out of the crib. The roster is incomplete and children files and/or required documents are missing.

LPA informed assistant Anthony Hernandez, that this report dated 09/29/2026, documents three (3) Type A citations that are an immediate Health and Safety, or Personal Rights risk to persons in care. In addition, two (2) Type B citations were issued that are a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for each deficiency.

Upon receipt of a Type A deficiency Licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and Licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with assistant Anthony Hernandez. LPA posted a notice of site visit. Assistant 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. A copy of this report will remain on file for a period of five years for public review upon request. The assistant’s signature on this form acknowledges receipt of this form.

Bettina Engelman
Corina Beckby
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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 5
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)
Page: 2 of 5
Document Has Been Signed on 09/29/2026 04:06 PM - It Cannot Be Edited


Created By: Corina Beckby On 09/29/2026 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA
FACILITY NUMBER: 393619809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2026
Section Cited
CCR
102425(j)(2)

1
2
3
4
5
6
7
Safe Sleep- (j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2) The provider shall check and document the following:
This requirement was not met, evidenced by
1
2
3
4
5
6
7
Sleep logs will be physically kept in the home and updated at actual time infants sleep and wake up.
Licensee will return to verify compliance.
8
9
10
11
12
13
14
Sleep logs were not available for 2 infants.
8
9
10
11
12
13
14
Type A
09/30/2026
Section Cited
CCR102417(d)(1)

1
2
3
4
5
6
7
Operation of family Child Care-(d) The home shall provide safe toys, play equipment and materials.(1) ...furniture...that have been banned or recalled by the United States Consumer Protection Safety Commission shall not be used for children in care or accessible to children in care.
This requirement was not met, evidenced by:
1
2
3
4
5
6
7
Licensee will remove bouncers.
LPA will return to verify compliance
8
9
10
11
12
13
14
1 infant was sleeping in a bouncer
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/29/2026 04:06 PM - It Cannot Be Edited


Created By: Corina Beckby On 09/29/2026 at 03:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA
FACILITY NUMBER: 393619809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2026
Section Cited
CCR
102425(i)

1
2
3
4
5
6
7
Safe Sleep-If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.
This requirement was not evidenced by:
1
2
3
4
5
6
7
Licensee will place baby in a crib provided as soon as the baby falls asleep.

Staff will watch Infant Safe Sleep video and write statements that they will comply with regulations.
8
9
10
11
12
13
14
LPA observed an infant sleeping in a bouncer.
8
9
10
11
12
13
14
LPA will return to verify compliance

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/29/2026 04:06 PM - It Cannot Be Edited


Created By: Corina Beckby On 09/29/2026 at 03:20 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA
FACILITY NUMBER: 393619809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2026
Section Cited
CCR
102417(g)(8)

1
2
3
4
5
6
7
Operation of a Family Child Care Home- (g)Operation of a Family Child Care Home (8) Each family child care home shall have a current roster...
This requirement was not met evidenced by:
1
2
3
4
5
6
7
Licensee will update and have a roster with all the information required for every child.

LPA will return to verify compliance.
8
9
10
11
12
13
14
Licensee has an incompete roster (date of births are missing)
8
9
10
11
12
13
14
Type B
10/09/2026
Section Cited
CCR102421(a)

1
2
3
4
5
6
7
Child's Records-(a)The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
This requrement was not met evidenced by:
1
2
3
4
5
6
7
Licensee will gather required files and documents by due date.

LPA will return to verify.
8
9
10
11
12
13
14
10 out of 29 children files were missing.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5