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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543908775
Report Date: 04/27/2022
Date Signed: 04/27/2022 08:40:18 PM

Document Has Been Signed on 04/27/2022 08:40 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JOHNSON, KYMBERLY FAMILY CHILD CAREFACILITY NUMBER:
543908775
ADMINISTRATOR:JOHNSON, KYMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 723-7056
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
04/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kymberly JohnsonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 4/27/2022, Licensing Program Analyst (LPA) conducted a complaint inspection and met with licensee, Kymberly Johnson.

This Case Management inspection is being conducted to address the issue of the $210.00 outstanding annual fees that are past due for this facility. The outstanding annual fee is $140.00 in addition to a $70.00 late fee. This payment may be mailed to Community Care Licensing office, 1310 E. Shaw Ave Fresno, CA. 93710, or Johnson can make the payment on line with the PIN that was provided to licensee today. Always include the facility number on all payments.

Per California Code of Regulation Title 22, Division 12, Chapter 1, the following deficiency was cited due to the outstanding fees. (continued on LIC809-D).

An exit interview was conducted and report was reviewed with the licensee Kymberly Johnson. A copy of Appeal Rights and the Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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 2
Document Has Been Signed on 04/27/2022 08:40 PM - It Cannot Be Edited


Created By: Theresa Marquez On 04/27/2022 at 11:46 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: JOHNSON, KYMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 543908775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
102384(a)

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LICENSING FEES- An applicant or licensee shall be charged fees as specified in Health and Safety Code Section 1596.803: This requirement was not met as evidenced by review of the facility transaction payment history.
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Licensee stated she will pay the outstanding annual fees of $210 online using the pin code provided to her today by 5/6/2022.
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Licensee owes a total of $210.00 which includes a $70 late fee. This poses a potential risk to the health, safety or personal rights 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:Susie Fanning
LICENSING EVALUATOR NAME:Theresa Marquez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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