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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494371
Report Date: 11/17/2021
Date Signed: 11/17/2021 12:13:34 PM

Document Has Been Signed on 11/17/2021 12:13 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ZAVALETA FAMILY CHILD CAREFACILITY NUMBER:
197494371
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Maritza Zavaleta, LicenseeTIME COMPLETED:
12:15 PM
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On 11/17/2021 9:10AM, Licensing Program Analyst (LPA), Denise Miranda, conducted an unannounced Annual Required Inspection and LPA met with Licensee, Maritza Zavaleta. Days and hours of operation are Monday-Friday 7:00Am– 4:00PM. During this inspection, Licensee provided an updated form LIC279 (application form for a FCCH).

LPA observed all required documents to be posted, posted in a publicly accessible area at facility. LPA toured the home inside and outside and observed no children present at this time. Per licensee, she has 3 children enrolled, but no one attended the day care today.

Current facility sketch reviewed and Licensee confirmed Living room #1 & #2 Bathroom#1, backyard are used for providing care and are accessible to children.

The following area are off limit: Bedrooms #1,#2 & #3 and Bathroom#2 and made inaccessible by use of door knob safety cover. Also, the attached garage and the kitchen area are off-limit. LPA observed that all cabinets and drawers located at the kitchen area have latches. There is no swimming pool or other bodies of water on the premises.

There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating (Central air) and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (323) 899-7095.

SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ZAVALETA FAMILY CHILD CARE
FACILITY NUMBER: 197494371
VISIT DATE: 11/17/2021
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There are currently no infants enrolled in care. Per licensee and application form (LIC279), Licensee served age group from 0 months to 13 years old. LPA discussed Safe Sleep Regulations with licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training completed 11/03/2021. Licensee’s pediatric CPR/First Aid expired on 08/20/2022. Per Licensee, no staff/volunteer is working now. All adults who reside in the home have a criminal record clearance or exemption.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Staff interview conducted and documented at 10:26AM.

Exit interview conducted and copy of this report was provided to Licensee.

SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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