Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274450199
Report Date: 05/03/2017
Date Signed 05/03/2017 02:41:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RIOS, NATIVIDADFACILITY NUMBER:
274450199
ADMINISTRATOR:NATIVIDAD RIOSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 442-0970
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:14CENSUS: 9DATE:
05/03/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Natividad RiosTIME COMPLETED:
02:50 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
LPAs Janet Tse and Fermin Campos-Jaramillo met with licensee Natividad Rios to conduct a follow-up visit for an unusual incident licensee reported to Licensing. A child fell backwards from a play structure in the home and about two days later the mother informed licensee that the child has suffered a fracture in his arm.

LPAs observed nine children including one infant with licensee and her husband, who is also her assistant, in the home during today's visit. A copy of the roster of the children and a copy of the doctor's report were given to LPAs during the visit.

LPAs toured the outdoor area of the home, and observed the play structure was age appropriate. LPAs observed the other play equipment in the outdoor area are safe and do not pose a danger to the health and safety to the children. LPAs interviewed licensee and her husband during the visit. Licensee's husband stated that he was with the child when the accident happened. It appears that the child was supervised.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2017
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