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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543908775
Report Date: 05/06/2022
Date Signed: 05/27/2022 08:58:11 AM

Document Has Been Signed on 05/27/2022 08:58 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, 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: 4DATE:
05/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kymberly JohnsonTIME COMPLETED:
02:45 PM
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On 5/6/2022, Licensing Program Analyst (LPA) Theresa Marquez conducted a Plan of Correction inspection and met with licensee, Kymberly Johnson. The purpose of this inspection is verify corrections have been made to clear the deficiency cited on 4/27/2022.

LPA observed the kitchen has dirty dishes, pots and pans in the sink and on the counters. The tile floor has dirt marks and is unclean. The living room area has adult and children's clothing, towels, household items, storage containers and children's toys on the furniture, desk, couches and on the floor. The bathroom observed to be neat and tidy. LPA Marquez observed the home is not clean and orderly.

Per California Code of Regulation Title 22, Division 12, Chapter 1, the following deficiency was cited: Licensee did not provide copies of the LIC9224, LIC9099 & LIC9099D (dated 4/27/2022) to daycare parents.

LPA Marquez informed licensee Kymberly Johnson that this report dated 5/6/2022, documents one (1) Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.
LPA Marquez also informed the licensee Johnson to provide a copy of this licensing report dated 5/6/2022, that documents any Type A citation 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.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100. 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: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 05/27/2022 08:58 AM - It Cannot Be Edited


Created By: Theresa Marquez On 05/06/2022 at 12:40 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2022
Section Cited
HSC
1596.8595(c)(1)

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REPORTS TO BE PROVIDED TO PARENTS OR GUARDIAN OF EACH CHILD RECEIVING SERVICES- (c)(1) A licensed child day care facility shall provide to the parents or guardians of ea. child receive services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.
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LPA provided 3 copies of the LIC9224 ACKNOWLEDGMENT OF RECEIPT OF LICENSING REPORTS to licensee today. Licensee stated she will provide the LIC9224, the LIC9099 and LIC9099D (both dated 4/27/2022 to parents by 5/7/2022.
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This requirement was not met as evidenced by record review. Licensee has not provided day care parents with copies of LIC 9224, LIC9099 & LIC9099D (dated 4/27/2022). This poses an immediate risk to the health, safety or personal rights of 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: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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