163911682-3-16-2022-04-CC-NLOI-CCKRJ5-20220316130322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 163911682
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:03:32 PM

Document Has Been Signed on 03/16/2022 01:03 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	REBOLLEDO, YADIRA FAMILY CHILD CARE		FACILITY NUMBER:	163911682
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	03/16/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Yadira Rebolledo		TIME COMPLETED:	01:15 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 March 16, 2022, Licensing Program Analyst (LPA), Norma Lomeli met with Applicant, Yadira Rebolledo for a pre-licensing inspection. Applicant, her husband, her adult son and four minor children reside in the home. Background clearances are discussed and LIS 531 is signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance. Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed: This is a single story, three bedrooms and two bathrooms home and children will have access to the living room, dining room, kitchen, hallway bathroom and converted day care room that was part of the garage. LPA observed in the day care room a vent on the ceiling that provides the room with heating and air conditioning. There is a day care entrance through the right hand side of the home's side run. Off-limits rooms are made inaccessible by use of plastic door knob covers. hours. LPA observed books and a flat screen television that will be mounted onto the wall. Children will nap in the living room on mats. Infants will nap in play yards. Applicant understands she is to supervise children at all times. LPA provided applicant with Individual Sleeping Plan and Safe Sleep handout. Facility has 2A10BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place. Applicant’s Pediatric CPR and First Aid certification was completed through Pediatric Plus with Emergency Medical Services Authority stickers (EMSA) and expires on April 23, 2023. (Continued on LIC809-C):

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: REBOLLEDO, YADIRA FAMILY CHILD CARE	FACILITY NUMBER: 163911682
	VISIT DATE: 03/16/2022

NARRATIVE

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Preventative Health and Safety with Prevention of Lead exposure certification was completed on May 5, 2021.
Knives are stored in a top kitchen cabinet inside a plastic container. Medications are stored in the master bedroom. Cleaning compounds are stored in the inaccessible laundry room.
Advised applicant fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
Applicant is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
There are no bodies of water in the home or premises.
There are two dogs that are kept in the backyard that will be inaccessible to the day care children. There is one cat that will be kept outdoors and will be inaccessible to the day care children. Applicant is advised it is her responsibility to ensure the safety of children in care at all times from the pets.
Applicant states there are no firearms or ammunition in the home or premises. Poisons are kept in the garage that will not be accessible to the day care children. Accessibility to the garage is by the use of a garage opener that will be inaccessible to the day care children.
Applicant is reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
Applicant is advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Applicant states the home is smoke-free.
Applicant states she will not be transporting day care children. Applicant understands that she must have proper car restraints and/or car seats for all the children under her care when transporting children.
Fenced backyard will be inaccessible to the day care children. Applicant states that the day care children will have access to the side run of the home and the home's fenced front yard. LPA observed in the front yard; patio furniture and a hammock. Applicant understands that she must have supervision of the children.

(Continued on LIC809-C):

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: REBOLLEDO, YADIRA FAMILY CHILD CARE	FACILITY NUMBER: 163911682
	VISIT DATE: 03/16/2022

NARRATIVE

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SB 792 immunizations verified and on file.
Applicant completed the Mandated Reporter Training on October 13, 2021.
LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given to applicant.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

Required postings, forms packet, which included Parent Notification Requirement and LIC9224 were provided and discussed in detail. Applicant is advised that she may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. She is also reminded that it is her responsibility to read the regulations periodically. Applicant states she will operate her day care Monday through Friday from 5:00am to 5:00pm and as arranged. No overnight care will be provided.

LPA & applicant discussed the Community Care Licensing website: LPA and applicant discussed new additions to the website that include the new PIN (Provider Information Notification) and information for providers including the Quarterly Update that informs licensees of new legislation and regulations. Please follow these steps go to http://www.cdss.ca.gov/, click on “information and resources” click “Community Care Licensing” Click “quarterly updates” click “Child Care advocates program” and register to PIN.

Applicant is advised the following item must be corrected and documentation be sent to Fresno CCL within the next 30 days to avoid possible withdraw.

Applicant will make inaccessible a hose that leads to the water heater that is located on the side run of the home. Applicant agrees to send proof of correction to LPA.

Pending verification of correction of the above item and a final review of her application, licensure as a Small Family Day Care Home capacity of 8 children ages under 18 years will be recommended.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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