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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620693
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:43:42 AM

Document Has Been Signed on 10/24/2023 10:43 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COSTA, CRISTINAFACILITY NUMBER:
313620693
ADMINISTRATOR:COSTA, CRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 488-6233
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Costa, CristinaTIME COMPLETED:
11:00 AM
NARRATIVE
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On October 24, 2023 at approximately 08:50 AM Licensing Program Analyst (LPA) Michelle Perez met with Licensee, Cristina Costa, for an unannounced one year inspection. During the inspection there was a census of 11 CHILDREN (three infants and eight preschoolers) supervised by the licensee and an assistant. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 6am to 6pm.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Daughter's room, Master bed/bath, kitchen, backyard and garage. During today's visit, licensee asked to put daughter's room off limits. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed wood burning stove within the home that is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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Document Has Been Signed on 10/24/2023 10:43 AM - It Cannot Be Edited


Created By: Michelle Perez On 10/24/2023 at 10:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COSTA, CRISTINA
FACILITY NUMBER: 313620693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, when LPA observed an infant inside of an exersaucer during the inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2023
Plan of Correction
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Licensee removed the exeraucer from the premisis immediately.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COSTA, CRISTINA
FACILITY NUMBER: 313620693
VISIT DATE: 10/24/2023
NARRATIVE
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LPA observed a children's roster and fire drill log, the last fire drill was conducted August 2023. Licensee's has current CPR/First aid, which expires October 2024. Licensee’s Mandated Reporter Training expires November 2024. Licensee understands both training’s must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation.

Incidental Medical Services (IMS) policy was discussed and not currently provided. 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) 514-0301 (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

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee is aware of safe sleep regulations and practicing them. Upon inspection, LPA observed an exersaucer with child in it, which is an infant item that is not allowed. Citation to follow on 809D.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COSTA, CRISTINA
FACILITY NUMBER: 313620693
VISIT DATE: 10/24/2023
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Deficiencies were cited during today’s inspection.

Today's visit resulted in one citation "A." A LIC 9224, will need to be signed by the parents of children currently enrolled, and all new parents of children enrolled for one year, from this day forward until October 24, 2024. The LIC 9224 shall be placed in each of the children's file.

Exit interview conducted and report was reviewed with the Licensee, Cristina Costa. A notice of site visit was provided and must remain posted for 30 days

Appeal Rights were provided.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
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