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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500395
Report Date: 04/20/2021
Date Signed: 04/20/2021 04:26:29 PM

Document Has Been Signed on 04/20/2021 04:26 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PINA, NIZARINDANDIFACILITY NUMBER:
394500395
ADMINISTRATOR:PINA, NIZARINDANDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 833-5761
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nizarindandi PinaTIME COMPLETED:
03:00 PM
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NOTE: Due to Covid-19 and DPH guidelines on physical distancing, a Tele-visit via FaceTime was conducted. On Tuesday, April 20, 2021, at 01:30PM, Licensing Program Analyst (LPA) Elvira Sierra conducted a Prelicensing visit for the purpose of change of location. Applicant was previously license under facility #.393621854. LPA explained about obtaining $300,000 liability insurance. Facility hours of operation will be M-F from 06:30 AM to 05:00 PM. All individuals residing in the home have obtained a criminal record clearance. Applicant's own children were present at the time of the visit. Applicant understands children under the age of 10 will count on her capacity when present. Fire clearance was granted for a capacity of 14 children and approved on 04/13/21.

At 01:45PM, with the help of the Applicant, a health and safety inspection was conducted and the following was observed. Home is a 6 bedrooms and 4 bathroom 2 story home. The Off-limits areas include; All bedrooms on the first floor, Kitchen, Garage, entire second level, backyard, front yard and driveway. Applicant acknowledged that children may never enter these off-limit areas. The home is equipped with at least one working carbon monoxide and a smoke detector. LPA observed a fully charged fire extinguisher that meet minimum size requirements. Stairs leading to the second floor are properly barricaded. Applicant states that chemicals and cleaning supplies are stored in the kitchen, and garage, both of which are inaccessible to children. Per Applicant medication is kept in one of the bedroom upstairs inaccessible to the children. LPA observed sufficient amount of age appropriate toys and furniture in well repair available for children. Per Applicant, there are no weapons or bodies of water on the premises. Backyard is under renovation and will remain off limits until renovation is completed. Applicant was advised that prior to making alterations or additions to the home or grounds, the applicant shall notify the Department of the proposed changes. Applicant understands that in unfenced area’s 100% supervision of children is required. Proof of control of property was provided.
Applicant has a current CPR that expires on 04/13/23. Mandated Reporter Training expires on 04/19/2023, applicant understands that the training must be updated every 2 years. Report continues on page 809C----
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: PINA, NIZARINDANDI
FACILITY NUMBER: 394500395
VISIT DATE: 04/20/2021
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LPA confirmed COVID-19 posters have been displayed at the entry of the home with the parents rights poster. The emergency disaster plan has been updated to reflect Health Department contact information and is posted on the entrance of the home. *LPA discussed guidance and practices regarding social and physical distancing for providers to prevent exposure to COVID-19 while providing care for children. COVID-19 Posting documents and the use of Personal Protective Equipment during COVID-19 Outbreak guidance*.

LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so applicant can request to be added to the distribution list to receive Quarterly Updates.


Effective today, 04/20/2021, this home is licensed for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants.
Facility evaluation report was emailed to Applicant and an email verification of receipt of report will be used in lieu of a signature on this report.** Please note: When a physical inspection takes place, requests for alterations may be made**

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC809 (FAS) - (06/04)
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