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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115408029
Report Date: 01/03/2022
Date Signed: 01/03/2022 09:41:48 AM

Document Has Been Signed on 01/03/2022 09:41 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:ZAPATA-MATA, JESSICA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115408029
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jessica Zapata-MataTIME COMPLETED:
09:50 AM
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
A pre-licensing inspection visit was conducted today by LPA, Emilia Grisak. This is in response to a change of location application that was received by CCL on 12/14/2021. The applicant is requesting a license for a capacity of 8. Services will be provided on Monday from 6:45am - 5:30pm and on Wednesday - Friday from 6:45am - 5:30pm. The applicant understands that child care must be provided in the "primary" residence of the applicant. The residence is a two bedroom/one bath home. There are two adults and two living in the home . 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.

The two bedrooms, garage and backyard are off limits to the children. These areas have been made inaccessible by means of door knob covers and door locks. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. There were no poisons observed to be present and applicant was advised that poisons must be locked when present. The applicant reports there are no weapons in the home and none were observed during the visit. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector and carbon monoxide detector. The children will eventually use the backyard as the outdoor play area and it is fully fenced. The applicant stated that the deck in the backyard will be replaced and until then the backyard is off limits to children. There is no pool, spa, pond, fountain, nor any other source of water accessible to the children, and none is to be added without prior notification and approval of the licensing agency.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Emilia Grisak
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2022
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: ZAPATA-MATA, JESSICA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115408029
VISIT DATE: 01/03/2022
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
Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property is on file. Parent's rights are posted near cubbies.. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current on Pediatric CPR and First Aid. The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current Pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant clearly understands the maximum number of children for whom care can be provided and 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 school aged. Smoking is prohibited during the hours of operation in those areas where children are present.

The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/
Megan's Law web site was provided (http://www.meganslaw.ca.gov). The licensee understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.


The facility is ready for licensure.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Emilia Grisak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2