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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423937
Report Date: 04/11/2024
Date Signed: 04/18/2024 09:26:30 AM

Document Has Been Signed on 04/18/2024 09:26 AM - 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:ZUBIZARRETAVELASCO, MAYRAFACILITY NUMBER:
013423937
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Mayra ZubizarettaVelascoTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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This is an amended version of the report dated April 11, 2024

On April 11, 2024 at 1:30pm, Licensing Program Analyst (LPA) Indira Loza arrived at the facility for an announced prelicensing inspection. LPA met with applicant Mayra ZubizarretaVelasco. The applicant lives in the home with her partner, Darlis Bernardes, minor child, and pet dog - a Yorkie. The home is on a lot with another house behind it, the address is 1456 Sixth Street. The applicant plans to operate Monday-Friday 8am - 5:30pm. LPA verified the applicant's phone number and email on record are correct.

LPA toured the home with the applicant, to conduct a health and safety inspection. LPA observed that the home is neat and clean with heating and ventilation for the safety and comfort of children. The home is a single family home consisting of a three (3) bedrooms, two (2) bathrooms, a fully fenced in front yard, and a backyard.

The Off Limit Areas are the first bedroom on the right, the master bedroom, and master bathroom, the backyard, the patio space outside from the bedroom, and the walkways on both sides of the house. The off limits areas are made inaccessible by gate, closed and/or locked doors and visual supervision.

The On Limit Areas are the living room, kitchen, first bedroom to the left of the hallway, and the bathroom to the left in the hallway.

Isolation Area - Next to the front door

Inside the home the LPA observed an ample supply of age appropriate toys, activities and equipment for children, which appeared to be safe and in good condition. LPA did not observe any medication, bodies of water, or poisons accessible to children during the inspection today. Per applicant there are no firearms in the home, The home is equipped with a fully charged 3A40BC fire extinguisher. The applicant has a

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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: ZUBIZARRETAVELASCO, MAYRA
FACILITY NUMBER: 013423937
VISIT DATE: 04/11/2024
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regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

On April 11, 2024 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

The applicant provided proof of control of property. The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 children.


Before a License is issued the applicant needs to send a photo of the cribs with appropriately fitting sheets and a picture of cots for non-crib age children.
Exit interview conducted. Report reviewed and provided to Applicant Mayra ZubizarretaVelasco.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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: ZUBIZARRETAVELASCO, MAYRA
FACILITY NUMBER: 013423937
VISIT DATE: 04/11/2024
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Mandated reporter certificate which expires on August 6, 2025. The applicant has a current CPR certificate which expires March 2025. The applicant plans on providing breakfast, lunch, and two (2) snacks. LPA observed a working combination smoke and carbon monoxide detector. The applicant plans on taking the children to play at the James Kennedy playground for outdoor play.

LPA reviewed all of the forms required for the children's files, facility file, posting and other information related to Licensing and the care of children. LPA left copies with the applicant. LPA advised the applicant of where to obtain additional copies of the forms. LPA reminded the applicant that the required documents must be visible for the public at all times during hours of operation. Applicant provided proof of property control. A copy of the Entrance Checklist (LIC126) was provided to the applicant.

LPA reviewed children's personal rights and the applicant advised that she understands that children's personal rights should not be violated and no corporal punishment is allowed. LPA reminded the applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. LPA reviewed fire/earthquake drill information, and how to complete the drill log. LPA demonstrated how to fill out the immunization record for children's files, discussed the applicant's responsibility to ensure the records are up to date, and have discussions with parents/guardians if they are not, and advised that it does not need to be done if children are enrolled in school. LPA reminded the applicant to report any injuries requiring medical attention or unusual incidents to the Oakland Regional Child Care office. LPA reviewed the form to follow up in writing within 7 days of the injury/unusual incident. The applicant was encouraged to periodically review regulations, guidelines and PINS on the website www.ccld.ca.gov.

LPA verified that the applicant, and all other adults living in the home, have a criminal record clearance and are associated to the license. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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