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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485408079
Report Date: 09/25/2024
Date Signed: 09/25/2024 10:01:30 AM

Document Has Been Signed on 09/25/2024 10:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VALENZUELA, MIREYA FAMILY CHILD CARE HOMEFACILITY NUMBER:
485408079
ADMINISTRATOR/
DIRECTOR:		VALENZUELA, MIREYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 770-5671
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 13DATE:
09/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Mireya Valenzuela - LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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 Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit and met with Licensee (LS), Mireya Valenzuela, for the purpose of addressing outstanding type B deficiencies. On 08/30/24, the facility was cited for not submitting an updated LIC 279 to reflect that an adult (A1) resided in the home, LS did not furnish Immunization Record (IR) for staff (S1) and child (C5), LS did not furnish complete records for C1-C3 & C5-C6; and evidence of negative Tuberculosis (TB) clearance for S1; and the POCs were due by 9/13/24. On 09/13/24, LS submitted a written statement to request an extension related to S1's TB clearance and the department extended the POC due date to 09/24/24.

During today's visit, LPA counted 13 children in care with LS and S1. The report citing a type A deficiency that was dated 08/30/24 and Notice of Site Visit were posted on the parent board near the facility entrance. According to LS, A1 moved out of the home 09/08/24 and A1 no longer resided in the home. On 09/24/24, LS submitted evidence of negative TB clearance and IR for S1 and completed records for C1-C3 & C5-C6. Furthermore, LS submitted IR for C1 and LS confirmed she mailed the updated application (LIC 279) to the department on 09/24/24, however; LS did not have evidence to prove that she mailed the application; but LS said the department should receive the updated LIC 279 soon. LPA reviewed twelve children's (C1-C12) records at 9:20am which revealed that the records contained Acknowledgement of Receipt of Licensing Report (LIC 9224) were signed by the children's guardian/authorized representatives. LPA cleared all pending deficiencies except for the deficiency related to California Code of Regulations (CCR) 102416.2(a)(2), generated and provided Letters of Deficiency Citations Cleared to LS.

Exit interview conducted and report was reviewed with the Licensee, Mireya Valenzuela. 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. There were no violation(s) of the California Code of Regulations, Title 22; Division 12, observed during today’s visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 1