<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115407899
Report Date: 04/27/2021
Date Signed: 06/29/2021 03:40:42 PM

Document Has Been Signed on 06/29/2021 03:40 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:CHAVEZ, PAULINA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115407899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
04/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Paulina ChavezTIME COMPLETED:
03:02 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/27/2021 at 2:00pm, Licensing Program Analyst (LPA) Laura Chavez conducted a prelicensing inspection in response to an application for a capacity of 8. The inspection was conducted via tele-inspection due to the current State of Emergency caused by COVID-19. During today's tele-inspection LPA discussed and reviewed the information from the COVID-19 Self-Assessment guide and posters. The applicant agrees to maintain COVID-19 posters posted. The applicant is the property owner. Days and hours of operation will be Monday-Friday; 7:00am-6:00pm. The applicant understands that child care must be provided in the "primary" residence of the applicant. The applicant understands that 24 hour care shall not be provided to one child at any one time. The home was toured inside and out. The residence is a three bedroom/two bath home. The three bedrooms and garage are off-limits. These areas have been made off-limits by means of doorknob covers. No poisons or hazards were observed inside the garage. The applicant understands that the electric fireplace located in the living-room shall be made off-limits to children should it be used while children are in care. Three adults and one minor reside in the home. The home is clean and orderly at this time and will remain so during child care hours. Electrical outlets were covered and cords to window blinds were not accessible. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. Poisons are locked in a shed located in a fenced off area of the back yard. There are age appropriate toys available for the children. There is a working smoke detector, carbon monoxide detector and a fully charged fire extinguisher in the home. The applicant stated there are no firearms and or other dangerous weapons in the home, and none were observed during today's inspection. Notification of Parents Rights, Emergency Disaster Plan with the Earthquake Preparedness Checklist shall be posted. The floor and yard plan were verified.

Report continued: See LIC 809-C
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CHAVEZ, PAULINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115407899
VISIT DATE: 04/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The children will use the back yard as the outdoor play area and it is fully fenced. Children will access the backyard by exiting through the front door. The applicant agrees to escort the children to the backyard as the front area of the home is not fenced in. The climbing/swing structure in the backyard is in good repair. The applicant agrees that the play structure shall be used per manufactures instructions. There is no pool, spa, or ponds, nor any other source of water accessible to the children, and none of these items are to be added without prior notification and approval of the licensing agency. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. Currently the applicant does not carry liability insurance for her family child care home. The applicant understands that parents will be required to sign insurance affidavits. A sample of forms typically given during prelicensing visits were provided. The applicant understands that the child care roster shall remain current at all times. Children's records are to be maintained and kept current at all times. The applicant was reminded of the responsibility of reporting unusual incidents to CCLD within 24 hours or the next business day. Megan's Law is available at www.meganslaw.ca.gov/. The following information regarding the American Disabilities Act (ADA) was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at https://www.ada.gov/childqanda.htm. The applicant clearly understands the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be one child in kindergarten or elementary school and one child at least age 6. Smoking is prohibited during the hours of operation. The applicants understand the responsibility of securing copies of forms and regulations from the website (www.ccld.ca.gov).

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2