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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422792
Report Date: 06/09/2021
Date Signed: 06/09/2021 04:17:51 PM

Document Has Been Signed on 06/09/2021 04:17 PM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LOPEZ, EMMAFACILITY NUMBER:
013422792
ADMINISTRATOR:LOPEZ, EMMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 287-6055
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Emma LopezTIME COMPLETED:
04:30 PM
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On 06/09/2021 at 02:00 PM Licensing Program Analyst (LPA) Arminder Singh met with Licensee, Emma Lopez and Assistant, for an unannounced random annual inspection. There are 9 children present. Licensee is in ratio in today's inspection. Records of three (3) children(c1-c3) were reviewed and are complete. Record of the assistant (s1) was also reviewed. The home was toured to conduct a health and safety inspection.

At 03:00 PM the home was toured to conduct a visual inspection. The home in single story with an attached garage. The hours of operation are Monday-Friday 8:00 AM -5:00 PM. The home consists of a 3 bedrooms, 2 bathrooms, children's room located near entrance, kitchen, dining room, living room, garage, atrium, and backyard.


The ON LIMIT AREAS are the children's room, bathroom #2 located in hallway, living room, dining room, kitchen, and back yard.

OFF LIMITS areas is the garage, atrium, bedroom #1, bedroom #2, bedroom #3, and bathroom #1.

The Outdoor play area was viewed and is properly gated and the play equipment is in good working condition. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. The atrium does have a pond but it is properly gated by sliding door and inaccessible to children. All hazardous materials and toxins are kept out of reach of children.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, and carbon monoxide detector. There is centralized heating that is working and in good repair. Licensee states there are no firearms in the home. Licensee conducts fire/disaster drills every six months.(01/2021) The Pediatric CPR and First Aid certificates for both Licensee and Assistant are current and expire on 02/08/2022. Licensee has a fully stocked first aid kit.

Please see LIC 809 C for additional information
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LOPEZ, EMMA
FACILITY NUMBER: 013422792
VISIT DATE: 06/09/2021
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This facility is not providing Incidental Medical Services - IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual.


REMINDERS/RESOURCES
· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

At 04:15PM Exit interview was conducted.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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