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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415983
Report Date: 04/26/2021
Date Signed: 04/26/2021 01:51:48 PM

Document Has Been Signed on 04/26/2021 01:51 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CONTRERAS, ADELAFACILITY NUMBER:
274415983
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/26/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adela ContrerasTIME COMPLETED:
12:00 PM
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On 0426/2021 at 10:00 AM, Licensing Program Analyst (LPA) Susy Cervantes conducted an announced pre-licensing tele-visit to the home. Tele-visit was conducted due to Covid-19. LPA met with Adela Contreras, Applicant, and explained the nature of today's visit to her. The adults that reside in the home are the Applicant, their spouse Gerardo, and their son Anthony with three children ages 17, 13, and 11. Days and hours of operation will be Monday - Saturday from 4:00 AM to 9:00 PM.

Applicant has completed her Preventative Health and Safety Child Care Training on 12/05/2020 and a copy of completion is on file. Applicant's CPR and First Aid certifications are current and expire on 12/01/2022. Mandated Reporter Training was completed on 11/09/2020. Applicant's son owns the home. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for FCCH.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 04/23/2021 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. LPA reminded Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA toured the indoor and outdoor areas during today's visit. LPA observed no stairs, no wall heater and a covered fireplace in the home. Off limit areas inside the home: three bedrooms, master bedroom, master bathroom, laundry room, and garage.

Continues on report dated 04/26/2021 pg. 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CONTRERAS, ADELA
FACILITY NUMBER: 274415983
VISIT DATE: 04/26/2021
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Continuation of report dated 04/26/2021 pg. 2/3

LPA observed a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, a fenced backyard, and no bodies of water. Off limit areas outside the home: left and right side yards that are gated. Applicant states that there are no weapons in the home and one pet, a dog, that the applicant stated is fully vaccinated. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children and stored under the kitchen sink, top kitchen cabinet, master bedroom, and laundry room. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

Forms of discipline used by Applicant: talking to children and redirection. Applicant understands that children's personal rights should not be violated; including no corporal punishment. A Family Child Care Home packet with updated Licensing forms was provided to and reviewed with the Applicant. Department website: www.ccld.ca.gov. provided to Applicant. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting unusual incidents/injuries, suspected child abuse (Mandated Reporter training AB 1207), SB 792 (Immunization's for Measles Pertussis and Influenza) and healthy beverages in child care, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Incident 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 415-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty, and an ongoing $100 per day per violation continues until the violation(s) is corrected.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CONTRERAS, ADELA
FACILITY NUMBER: 274415983
VISIT DATE: 04/26/2021
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Continuation of report dated 04/26/2021 pg. 3/3

LPA conducted an exit interview with the Applicant in Spanish. LPA informed applicant that the report will be emailed to them. Licensee understands that in lieu of a signature, a read receipt or confirmation of receiving the report email must be submitted within 24 hours.
LPA advised applicant that Licensure for a small family child care home is granted pending the following:

- Management's approval.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC809 (FAS) - (06/04)
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