364816117-1-4-2024-09-CC-ASHA-CZ6VH3-20240104152629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364816117
Report Date: 12/15/2023
Date Signed: 01/04/2024 03:26:39 PM

Document Has Been Signed on 01/04/2024 03:26 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	CHAVEZ FAMILY CHILD CARE		FACILITY NUMBER:	364816117
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 7	CENSUS: 1	DATE:	12/15/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Dolores Chavez		TIME COMPLETED:	11:10 AM

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On date and time listed, Licensing Program Analyst (LPA) Aman Sharma arrived at the facility to conduct a required annual inspection. LPA came to the facility during an earlier date, but the licensee was unavailable. Upon arrival, LPA was met with another adult, who stated licensee went to pick up children. No children were in the home during this interaction. Approximately 10-15 minutes later, LPA observed a van pull up to the home and walked over and knocked on the door. LPA was granted access to the home, and met with licensee. LPA toured the home, both inside and outside.

Normal days and hours of operation are listed as Monday-Friday, 6am-6pm. Licensee agrees to keep licensing updated on dates she will be closed/not operating.

Licensee was also advised to update and submit the following forms to licensing within 30 days of todays date: Emergency Disaster Plan, (LIC610A), Facility Sketch (LIC999A) and Application (LIC279).

OFF-LIMIT AREAS ARE LISTED AS FOLLOWS: All bedrooms, the garage and outdoor side yard.

· The facility is operating within the licensed capacity and appropriate ratios

· Appropriate supervision was being provided during this inspection.

· A working telephone is present and current phone number is on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector were all in working order.

· The fireplace is screened off and not accessible to children in care.

· Hazardous items and toxins were observed to be in on-limit areas of the home and accessible to daycare children.

· No weapons are present in the home at this time. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAVEZ FAMILY CHILD CARE	FACILITY NUMBER: 364816117
	VISIT DATE: 12/15/2023

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·Verification of control of property is on file.

· Postings were observed in the home: Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster were posted in the home.

· Appropriate Mandated Reporter Training for licensee has been updated and expires 11/15/2024.

· Pediatric CPR and First Aid Card for licensee was on file and expires 12/2025.

· Health & Safety Certificate has been completed on 02/28/2004.

· Bodies of water were not observed on property at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Clean, safe and age appropriate toys were available to the daycare children.

· A complete and updated roster was made available during today’s inspection.

· Documentation of fire and disaster drills are on file – Last drill was conducted on: 11/18/2023

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov

· Children’s and licensees records were made available and observed to be complete during today’s inspection.

· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations862@dss.ca.gov

-Incidental 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.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAVEZ FAMILY CHILD CARE	FACILITY NUMBER: 364816117
	VISIT DATE: 12/15/2023

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-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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- The Duty Officer is available to answer questions Monday – Friday, 8am to 5pm at: 951-782-4200
-Complaint hotline is also available Monday-Friday, 8am-5pm

The Licensee, Dolores Chavez confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee, Dolores Chavez.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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