Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 503908818
Report Date: 10/10/2017
Date Signed 10/10/2017 02:18:51 PM


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
10/05/2017 and conducted by Evaluator Alice Juarez
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20171005122414
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: 7DATE:
10/10/2017
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa PershallTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee failed to associate individual to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Alice Juarez conducted an unannounced complaint inspection for the above allegation a file review was completed prior to visit. LPA met with Licensee, Melissa Pershall. LPA explained the allegation, and the transfer process to licensee. LPA observed seven children during today’s visit. LPA interviewed licensee and reviewed facility records.

Based upon LPA Juarez' observations which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, this deficiency is to be cited.
See LIC9099-D:
Exit interview conducted with the licensee, Melissa Pershall. Plan Of Correction/Appeal Rights were given and discussed. A Notice of Site Visit was posted on parent board.

A COPY OF THIS REPORT IS TO REMAIN IN THE FACILITY FOR PUBLIC REVIEW.
THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
To order forms, etc. visit our website at www.ccld.ca.gov
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Alice JuarezTELEPHONE: (559) 341-5280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 04-CC-20171005122414
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: PERSHALL, MELISSA FAMILY CHILD CARE
FACILITY NUMBER: 503908818
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2017
Section Cited
CCR
102416(d)(2)(3)
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Personnel Requirements:
Licensee failed to associate individual to the facility. Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall: Request and be approved for a transfer of a criminal record.
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Licensee shall immediately request and be approved for a transfers of a criminal record as specified in Section 102370.1(p), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Alice JuarezTELEPHONE: (559) 341-5280
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2017
LIC9099 (FAS) - (06/04)
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