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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409250
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:08:31 PM

Document Has Been Signed on 04/03/2024 01:08 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:AYALA, ANAFACILITY NUMBER:
073409250
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Ana AyalaTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 4/3/24, Licensing Program Analysts (LPAs) Brindha Govindasamy and Monica Mathur arrived at the home for an unannounced annual inspection and met with licensee Ana Ayala. Present in the home were 1 infant, 3 preschool age and 2 school age children in care during the inspection. This family childcare home operates Monday - Friday 7am to 5pm.
LPA toured the home with Ana, 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 in care.

The on-limit areas include : Front yard, Living room, Bathroom #1, Dining area, Kitchen, Backyard
The off-limit areas include : All 3 Bedrooms, attached garage, Bathroom #2, Hallway, Laundry area, 2 storage units in the backyard and side yard.

Off limit areas are made inaccessible by closed and/or locked doors, gates, and visual supervision. LPA observed locks on cabinets to prevent access by children. The corner of the living room is used for isolation of sick children, away from other children in care. The fenced back yard is used for outdoor play. LPA observed sufficient supply of age-appropriate toys, equipment and activities available for children both indoors and outdoors and observed that they are in good condition. LPA did not observe any bodies of water. The licensee stated that there are no firearms on the premises.
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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Brindha Govindasamy
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: AYALA, ANA
FACILITY NUMBER: 073409250
VISIT DATE: 04/03/2024
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The home is equipped with fully charged 3A10BC fire extinguisher, a working carbon monoxide detector and smoke detector, working telephone first aid kits and supplies. Licensee has proof of current CPR/First aid certificates which expire on 3/2026 The last documented fire drill was conducted on 1/12/24. LPA observed all of the required forms posted. reviewed children's files, staff files.

Licensee Ana was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

LPA reminded the licensees that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. LPA provided the main office number for the Oakland Regional Child Care office (510) 622-2602 for the licensees to call and report injuries or unusual incidents and reviewed the form to follow up in writing within 7 days of the injury/unusual incident. The licensees were encouraged to periodically review regulations, guidelines and Provider Information Notices (PINs) on the website www.ccld.ca.gov.

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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Brindha Govindasamy
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: AYALA, ANA
FACILITY NUMBER: 073409250
VISIT DATE: 04/03/2024
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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 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: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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

There were no deficiencies cited during todays visit. Technical Advisory Notes were issued for Sleep Log, Clearance, Inaccessibility to off limit areas, Employee records.

Exit interview conducted and report was reviewed with the licensee Ana Ayala. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Brindha Govindasamy
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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