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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500395
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:25:25 AM

Document Has Been Signed on 03/08/2023 11:25 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:PINA, NIZARINDANDIFACILITY NUMBER:
394500395
ADMINISTRATOR:PINA, NIZARINDANDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 833-5761
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nizarindandi PinaTIME COMPLETED:
11:45 PM
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On March 08, 2023, Licensing Program Analyst (LPA) Erwin Tjhia met with Licensee, Nizarindandi Pina for the purpose of an unannounced annual inspection. There were 5 preschoolers and 1 infant present at the time of inspection. Licensee's operating hours are Monday through Friday from 6:30 AM. to 5 PM.

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.

A health and safety inspection was conducted in all areas accessible to children. Off-limits area include the entire upstairs, the garage, backyard, and licensee's bedroom. LPA observed the required postings and a working phone. 3B40BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives and cleaners were inaccessible to children in care.

Licensee stated there are no weapons in the home. There are no bodies of water on the premises. LPA observed living room area with age appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care.

LPA discussed the infant sleep regulations with licensee. LPA discussed the requirement to check and log infant napping every 15 minutes / observed 15min infant napping logs for infants 24 months and under. LPA provided a copy of LIC 9227 Individual Sleeping Plan, for infants under 12 months, for licensee during today's inspection.

Report Continue on 809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: PINA, NIZARINDANDI
FACILITY NUMBER: 394500395
VISIT DATE: 03/08/2023
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LPA also discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

LPA verified the annual fees are current. Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed documentation that a fire drill is conducted at least once every six months. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires 06/2025 and Child Care Provider Mandated Reporter certification was verified and expires 04/2023.



This provider is not currently providing IMS services to children in care. 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. 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

Exit interview conducted and report was reviewed with the licensee. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



In the areas that were evaluated, no deficiencies were cited during today’s inspection
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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