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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409250
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:03:16 PM

Document Has Been Signed on 05/18/2022 04:03 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:AYALA, ANAFACILITY NUMBER:
073409250
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ana AyalaTIME COMPLETED:
04:05 PM
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On 5/18/22 at 1:30 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an announced Pre-licensing Inspection at Ana Ayala home and met with Applicant, Ana who has applied for a Small Family Child Care Home with a capacity of 8 children. The home was toured to conduct a Health and Safety Inspection. Present during today’s inspection is applicant Ana. The Child Care home plans to operate Monday-Friday from 7AM- 5PM. Living in the home is applicant, applicant's spouse, adult son and adult friend.

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.

INDOOR SPACE: LPA toured the indoor space of the home. The home consists of living room, dinning room, kitchen, back yard, garage, 3 bedrooms and 2 bathrooms.

IN-USE AREAS: Living room, dinning room, kitchen, bathroom 1, front yard and backyard.

OFF-LIMIT AREAS: All bedrooms, bathroom 2 and garage.

OUTDOOR SPACE: LPA toured the outdoor area (backyard). LPA observed 2 sheds with locks. There are no water body in back yard. LPA observed the backyard is fully fenced and gates for the off-limit areas in the yard.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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: AYALA, ANA
FACILITY NUMBER: 073409250
VISIT DATE: 05/18/2022
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LPA observed: fully charged 3A40BC fire extinguisher, working dual smoke and carbon monoxide detector in kitchen. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and drawers with latches. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant states that there are no pets or arms and ammunition stored in the home.

At 3:45PM Discipline policy was discussed, and Applicant stated she sit with the children and talk about their feelings, get children to communicate and the use of quiet time. Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children in the is in the living in the library area, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented.

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 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

Exit interview conducted and report was reviewed with the applicant Ana Ayala.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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: AYALA, ANA
FACILITY NUMBER: 073409250
VISIT DATE: 05/18/2022
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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.

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.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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