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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700387
Report Date: 05/16/2023
Date Signed: 05/16/2023 10:07:13 AM

Document Has Been Signed on 05/16/2023 10:07 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:BORJON, BRENDAFACILITY NUMBER:
015700387
ADMINISTRATOR:BORJON, BRENDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 921-0251
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/16/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Brenda BorjonTIME COMPLETED:
10:05 AM
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On 5/16/2023 at 8:00am Licensing Program Analyst (LPA) Morgan Pringle met with Applicant Brenda Borjon for an Announced Pre-Licensing Visit for a Change of Location. Present during the inspection was the Applicant. Applicant lives in the home with her husband, Carlos Flores. The Applicant’s home was toured for a health and safety inspection. The facility plans to operate 7:00am – 5:00pm, Monday – Friday.

ON LIMITS AREA: Living Room, Dining Area, Kitchen, Bedroom at end of Hallway, 1st Bedroom on the left side of the Hallway, Bathroom and Backyard


OFF LIMITS AREA: 2nd Bedroom on the left side of the Hallway and Garage
ISOLATION AREA: Bedroom at end of the Hallway

The home has gained a fire clearance on 2/14/2023 from the Fremont Fire Department with the condition that the garage is off limits to children.

The facility is a single-story home rented by the Applicant. The home consists of three bedrooms, one bathroom, kitchen, living room, dining area, garage, and a backyard.

The inside of the home is observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, medications and hazardous materials were observed to be in inaccessible areas. All off limit areas in the home will be made inaccessible with closed doors and locks. There is a wall heater in the hallway that has been barricaded and is no harm to the children. The home has centralized heat and air for proper ventilation. LPA did not observe any harmful bodies of water in or around the home. Applicant stated that she does not transport children. Applicant will provide all food for the children. All food that is brought from the children's home will be properly labeled and stored.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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 3
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: BORJON, BRENDA
FACILITY NUMBER: 015700387
VISIT DATE: 05/16/2023
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The back yard is fully fenced with ample age-appropriate materials for the children. There are four (4) sheds that are locked and made inaccessible to the children. Applicant stated that two of the sheds belong to the owner. All sheds are used for storage. There are two play structures that are in proper working order and well maintained. The right side of the backyard is fenced off and made inaccessible to the children in care.

There is a 2A10BC fire extinguisher in the dining area. There are working smoke/carbon monoxide detectors in all three (3) bedrooms and in the hallway. The Applicant’s Health and Safety training with the lead poisoning component has been completed and Pediatric CPR and First Aid certificates are current and expires on 7/23/2023. Mandated Reporter training's are complete and expires on 5/7/2025. All adults living, and those that will be working in the home, have obtained a criminal record clearance. Applicant has provided immunizations for influenza, measles, pertussis and has a current record of tuberculous.

Applicant were reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the Applicant that all forms can be downloaded at www.ccld.ca.gov. Applicant were also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Applicant were reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Applicant were reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: BORJON, BRENDA
FACILITY NUMBER: 015700387
VISIT DATE: 05/16/2023
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Applicant were reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-and-resources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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.

Exit interview conducted and report was reviewed with the Applicant Brenda Borjon.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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