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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 543908775
Report Date: 04/27/2022
Date Signed: 04/27/2022 08:27:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Theresa Marquez
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20220419140733
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:14CENSUS: 2DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kymberly JohnsonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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The facility is not kept clean.
INVESTIGATION FINDINGS:
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On 4/27/2022, Licensing Program Analyst (LPA) Theresa Marquez conducted a complaint inspection and met Licensee Kymberly Johnson.

LPA Marquez toured the home and observed 2 children present, including licensee's own child. The fenced backyard is off limits. LPA Marquez observed various household items scattered about the home, the playroom, living room, on the kitchen counters and on the furniture; children's clothing, adult clothing, food/food containers, and toys. Food particles and dirt were also observed on the tile floor throughout the home. The bathroom used by day care children observed to be cluttered with shampoo bottles and body wash bottles on the corner floor near the bathtub. The bathroom garbage can was overflowing with soiled diapers, toilet paper and garbage.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 04-CC-20220419140733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 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 A
04/28/2022
Section Cited
CCR
102417(b)
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OPERATION OF A FAMILY CHILD CARE HOME - The home shall be kept clean and orderly. This requirement was not met as evidenced by LPA observation. LPA observed various household items scattered about the home, the playroom, living room, on the kitchen counters and furniture: observed children's clothing,
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Licensee agreed to remove all garbage and keep out of reach items from accessible rooms by 4/28/2022. Licensee agreed to clean, organized and keep orderly all other inaccessible rooms by 5/4/2022.
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adult clothing, food/food containers, and toys. Food particles and dirt were also observed on the tiled floor. The bathroom used by day care children observed to be cluttered with various shampoo bottles and body wash on the corner floor near the bathtub. Bathroom garbage can was overflowing with soiled diapers, toilet paper & garbage. This poses an immediate risk to the health, safety or personal rights to children in care.
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Licensee will submit proof to LPA Marquez. LPA Marquez will return for a Plan of Correction visit.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 04-CC-20220419140733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 543908775
VISIT DATE: 04/27/2022
NARRATIVE
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Based on LPAs observations, there is a preponderance of the evidence to prove the facility is not kept clean, therefore, the allegation is substantiated.
Per California Code of Regulation Title 22, Division 12, Chapter 1, the following deficiency was cited. (see page LIC9099-D).

LPA Marquez informed licensee Kymberly Johnson that this report dated 4/27/2022, 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 4/27/2022, 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3