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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010078
Report Date: 06/08/2021
Date Signed: 03/15/2024 05:38:36 PM

Document Has Been Signed on 03/15/2024 05:38 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GONZALEZ, ITZAYANA FCCHFACILITY NUMBER:
173010078
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
06/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Itzayana GonzalezTIME COMPLETED:
05:40 PM
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A Facetime video conference (change of location) Pre-Licensing inspection was conducted today by Licensing Program Analyst (LPA), Leticia Rosales-Meza. The applicant is Spanish Speaking. Due to the COVID-19, the Department has suspended all field operations, and the applicant agreed to attend the Tele-Inspection conference with LPA. The applicant was previously licensed at 5575 Old Highway 53, SPC 25. The applicant is requesting a license for a capacity of 8 children. Services will be provided Monday - Sunday 5:00 AM - 6:00 PM. The applicant understands that 24hr consecutive care is prohibited. The applicant understand that childcare must be provided in the "primary" residence of the applicant. The residence is a three bedroom, two bath mobile home. There are two adults 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 applicants are aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.

During the Tele-Inspection, the applicant provided a virtual tour of the entire facility and backyard. The day care areas will be the living room, kitchen/dining area, hallway bathroom and one bedroom will be used for napping and play space. The other two bedrooms are "off limits" to the day children, and were made inaccessible by door knob covers. The floor plan submitted by the licensee was reviewed and verified. During the video LPA observed electrical outlets were covered and drapery cords are not accessible. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. There is a working smoke detector, carbon monoxide detector and fire extinguisher in the home. The applicant stated there are no Firearms or Weapons, and none were observed during today's Tele-Inspection. Applicant stated there are no poisons in the home. The requirement that poisons be stored in a space locked with a key lock/combination lock is reviewed. First Aid supplies are kept in the kitchen.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: GONZALEZ, ITZAYANA FCCH
FACILITY NUMBER: 173010078
VISIT DATE: 06/08/2021
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The children will use the front and side area as the outdoor play and it is fully fenced. The backyard and storage shed is "off limits". No bodies of water were observed during the video inspection. There is no trampoline, pool, pond, or fountain observed during today's Tele-Inspection. Pediatric CPR and Pediatric First Aid cards expire on 04/2023. All licensing reports are public information and must be made available upon request for at least three years.

Based on this video inspection, the facility meets licensing requirements. The license is granted and is now licensed as a Small Family Child Care Home.

The Applicant's signature was not recorded on this Facility Evaluation Report (LIC 809 & LIC 809-C), however, the Applicant was provided with a copy of this report; and the Applicant's proof of Read Receipt is on file. LPA also mailed a copy of this report to the Applicant.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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