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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015701195
Report Date: 11/26/2024
Date Signed: 11/26/2024 01:18:51 PM

Document Has Been Signed on 11/26/2024 01:18 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CAMPOS, GLORIAFACILITY NUMBER:
015701195
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Gloria CamposTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On November 26, 2024, at approximately 12:00 PM., Licensing Program Analyst (LPA) Lorraine Dacanay Breaux conducted an announced Pre-licensing Inspection and met with applicant, Gloria Campos. LPA disclosed the purpose of the inspection and was granted entry into the facility by the applicant. There were no children present during this inspection. The facility was toured to conduct a health and safety inspection. The facility plans to operate between the hours of 6:00 AM- 06:00 PM, Monday -Friday. Applicant plans to care for children from infant - school age.

This single story home (duplex) consist of three (3) bedrooms, two (2) bathrooms, kitchen, living room, backyard, and two car garage which is neat and clean with heating and ventilation for safety and comfort. The off-limits will be made inaccessible by closed and/or locked doors and visual supervision. LPA checked the cabinets in the kitchen, bathroom, on-limits and any other cabinets or drawers accessible to children in care. The Isolation area will be a section of the dining area, away from other children in care.

There is a chimney located inside the living room which has a barricaded child gate placed around to prevent access by children. Per applicant, does not utilize the chimney.

On-limit-areas: Kitchen, living room, dining room, main bathroom down the hallway and rear yard.



Off-limit-areas: All bedrooms which includes a master bedroom and bathroom, the front yard and a section in the rear yard to the left (gated) and the two car garage.

The outdoor play area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. 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 present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. Applicant confirmed there are no pools/bodies of water at the home. Applicant confirmed that she resides in the home. Applicant stated that she will provide transportation as needed, LPA reviewed Driver's License which is current/valid.

See 809-C
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CAMPOS, GLORIA
FACILITY NUMBER: 015701195
VISIT DATE: 11/26/2024
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LPA tested the smoke detector in the hallway and the carbon monoxide detector in the living room and found them to be functioning properly. The applicant has a fully stocked first aid kit and a fully charged 3A40BC fire extinguisher which meets standards established by the State Fire Marshal located in the living room. Per applicant, there are no firearms in the home. The applicant in compliance with the immunization laws which pertains to all childcare providers.

A copy of the rental agreement was reviewed and shows control of property. The applicant completed and received a certificate in mandated reporter training on 08/2/2024. Licensee's CPR and First Aid certificate is current and expires 09/2025.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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 Per applicant does not plan to administer medication at this time.

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 at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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.

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, 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.

See 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CAMPOS, GLORIA
FACILITY NUMBER: 015701195
VISIT DATE: 11/26/2024
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LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov and encouraged the applicant to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The applicant was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com. CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

Effective August 1, 2003 California Law requires Family Child Care Home 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 electronic mail.

Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented. The applicant is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

Applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare 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

During the exit interview, the applicant, Gloria Campos confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Entrance Checklist was provided to the applicant.

Exit interview conducted and report was reviewed with the applicant, Gloria Campos. This home is recommended for Licensure on 11/26/2024.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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