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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624596
Report Date: 11/28/2022
Date Signed: 11/28/2022 11:37:03 AM

Document Has Been Signed on 11/28/2022 11:37 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MOLINA, GIOVANNAFACILITY NUMBER:
293624596
ADMINISTRATOR:MOLINA, GIOVANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 837-2769
CITY:NEVADA CITYSTATE: CAZIP CODE:
95959
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Giovanna MolinaTIME COMPLETED:
11:50 AM
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At 9:50 a.m. on Monday, November 28th, 2022, Licensing Program Analysts (LPAs) Karyn Guerra and Matthew Gallo met with Applicant, Giovanna Molina, for the purpose of an announced prelicensing inspection. All individuals subject to criminal background review have obtained criminal record clearance. Applicant guided LPAs on a tour of the home. The two story home consists of 2 bedrooms, 4 bathrooms, living room, lower level, office, sunroom, deck and kitchen. The off limits areas of the home will be the garage, half bathroom, sunroom, master bedroom, deck, and office. Applicant understands that their own children under 10 years old will count toward the child care ratio when present at the facility during child care hours. Hours of operation are 7:00 a.m.- 4:00 p.m., Monday thru Thursday.

Applicant owns the home and has provided a mortgage statement showing proof of control of property. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. CPR and First aid certification was verified and will expire on 12/2023. Mandated Reporter training was verified and will expire April 2023. LPA provided blank forms required for children's records including immunization card and emergency identification. LPA also provided the Parent's Rights form/poster, reviewed vaccination requirements for children.

There are no bodies of water on the premises. The facility has well water. Backyard is currently under construction and partially fenced. Applicant will follow up for a safety inspection when backyard construction is complete. Applicant understands 100% supervision shall be maintained in or around bodies of water, and in unfenced areas. Applicant stated that there are no weapons nor poisons in the home. Cleaning compounds, knives and medications are inaccessible to children. There is a wood burning stove in the living room, however, applicant stated that it is not used during the day time as there are alternate heating sources in the home. Applicant stated that they will be adding a space heater to the downstairs play space.

LPA observed functioning smoke and carbon monoxide detectors, and a 2A10BC fire extinguisher that meets regulatory standards.

(report continued on 809-C)

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MOLINA, GIOVANNA
FACILITY NUMBER: 293624596
VISIT DATE: 11/28/2022
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Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Applicant will follow up with documentation of crib or play yard purchase.

Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624B shall be submitted within seven days to remain in compliance.

Applicant understands that if any changes are made to the off limits of the home; licensing must be notified and a safety inspection conducted prior to any child care children being able to have access to the area.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Effective today, Monday, November 28th, 2022, facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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