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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409256
Report Date: 04/01/2022
Date Signed: 04/01/2022 10:52:37 AM

Document Has Been Signed on 04/01/2022 10:52 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:ORELLANA, FANYFACILITY NUMBER:
073409256
ADMINISTRATOR:ORELLANA, FANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 713-2152
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Fany OrellanaTIME COMPLETED:
11:00 AM
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On 4/1/22 at 8:45 AM Licensing Program Analysts (LPAs), Monica Mathur and Diana Campos conducted an announced Pre-licensing Inspection at Fany Orellana's home and met with Applicant, Fany who has applied for a Large Family Child Care Home with a capacity of 14. Present in the home during inspection were Applicant, adult daughter and 2 minor children. Days and hours of operation will be Monday – Friday from 6 am - 6 pm. Other adults residing in the home are her spouse and daughter. There are 2 additional children under age 10 living in the home. Fany states her adult daughter and spouse will be Helpers in the day care.

Applicant completed 8-hour Preventative Health & Safety training, Nutrition and Lead Poisoning training, 8 hour Pediatric CPR & First Aid, has documentation for Measles, Pertussis, Influenza verification for the current flu season. Applicant and adults living in the home have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant owns the home and has submitted proof of control of property. LPA reminded that when care for more than 12 and up to 14 is provided, Applicant must notify parents. Applicant will use the Affidavit Regarding Liability Insurance form to inform parents she does do not carry a day care insurance. Applicant has a working telephone in the home.

Single story home comprises of 3 bedrooms, 2 bathrooms, Kitchen, Living/Dining room, attached Garage
Areas to be used for day care: Living/Dining space, 1 bedroom for naps (first room left side of hallway, across from bathroom), Bathroom in hallway
Off-Limit Areas: 2 bedrooms, Kitchen, attached Garage
Isolation Area: Bedroom
LPA toured the indoor space of the home. Fire clearance was received approving the home to be licensed for large family child care. It is sanitary and orderly, with heating and ventilation for safety and comfort. There are no stairs, fireplace or wall heaters in the home.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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: ORELLANA, FANY
FACILITY NUMBER: 073409256
VISIT DATE: 04/01/2022
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LPA observed fully charged 2A10BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets with latches and locks. Access to Off limits bedrooms is barricaded by a child proof gate. LPA reminded that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant states there is 1 pet dog and no arms and ammunition stored in the home. There is a small fish aquarium placed on the kitchen counter (inaccessible in off limit area)

Outdoor Space: LPA toured the outdoor areas. Children will be using the entire backyard for outdoor activity. The yard has fences on all sides. No bodies of water were observed. A Storage shed will be kept locked. LPA observed an air conditioning unit in the side yard. Applicant states it is not in working condition. LPA reminded Applicant to ensure yard is clean and sanitary before children are present outside. There is a heavy large play structure which is bolted to the ground. Applicant stated they plan to do some construction in the backyard at a later date. She was informed when any major structural change or construction is planned, Applicant should inform Licensing office before start.

Discipline policy was discussed, and Applicant states she will talk to the children as form of discipline. She understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children, 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. A Family Child Care Home packet was provided to and reviewed with the Applicant. Applicant will provide meals and snacks.

LPA reviewed with Applicant the LIC311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
LPA discussed and reminded Applicant day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours. Applicant understands her children under age 10 will count in the ratios when they are present at home with other day care children.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
Page: 3 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ORELLANA, FANY
FACILITY NUMBER: 073409256
VISIT DATE: 04/01/2022
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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



LPA discussed the safe sleep regulations with Applicant, and discussed the Child Care Licensing Safe Sleep web page 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.

Website links for provider resources:


Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.

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.

Home is approved to be licensed as Large Family Child Care Home.
Exit interview conducted and report was reviewed with the Applicant, Fany Orellana
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
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