Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503908818
Report Date: 05/05/2015 12:00:00 AM
Date Signed 05/05/2015 11:13:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:PERSHALL, MELISSA FAMILY CHILD CAREFACILITY NUMBER:
503908818
ADMINISTRATOR:PERSHALL, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 869-5900
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:14CENSUS: 12DATE:
05/05/2015
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee, Melissa PershallTIME COMPLETED:
11:25 AM
NARRATIVE
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On this date LPA Kathie Campbell conducted an unannounced Case Management visit. Met with licensee and three assistants. A tour of the home was made. Home has a pool that has regulatory fencing and gate that is self closing/self latching. Family has a pet that is allowed access to the children. Liabilities/safety were discussed. LPA and licensee discussed outstanding annual fees. LPA and licensee reviewed LIS printout, dated 4/20/2015, indicating that her fees are outstanding. Licensee was provided with a copy of her facility transaction history.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found (see next page): Exit interview was conducted. Appeal Rights were discussed and left with licensee.

During exit interview, LPA gave instructions to post LIC9213 for 30 days. This report must be kept in your facility and available for public review for at least three years.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)243-4588
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2015
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME: PERSHALL, MELISSA FAMILY CHILD CARE
FACILITY NUMBER: 503908818
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2015
Section Cited
102384(a)(e)
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LICENSING FEES: An applicant or licensee shall be charged fees as specified in Health and Safety Code Section 1596.803. After initial licensure, a fee shall be charged by the department annually, on each anniversary of the effective date of the license. Licensee currently owes as of today a total of $260.00 for annual and accrued fees.
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Licensee stated she has always paid her fees and disputes that she owes fees. Licensee stated that she does not want to pay the fee yet because she wants to investigate this further. Licensee will ensure all fees are resolved/paid by 5/19/2015. Licensee stated she will supply LPA with copies of cancelled checks, front and back, showing they have been cashed.
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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: Duane MatsubaraTELEPHONE: (559)243-4588
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2015
LIC809 (FAS) - (06/04)
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