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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004818
Report Date: 08/03/2021
Date Signed: 08/03/2021 12:03:23 PM

Document Has Been Signed on 08/03/2021 12:03 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CARBALLO RAMOS, AIDA VIRGINIAFACILITY NUMBER:
414004818
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aida Carballo RamosTIME COMPLETED:
12:20 PM
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On August 3, 2021 at 11:00 AM, Licensing Program Analyst (LPA) Cowan conducted an announced pre-licensing inspection for relocation and capacity change. Present in the home this day is applicant, mother, and minor child. Applicant lives in the home with spouse, mother, and two minor children. Applicant’s home is a four bedroom and four bathroom home. Day-care areas: bedroom 4, lower level family room, and back yard. Off Limit areas: Upper level living room, kitchen, bedrooms 1, 2, and 3, and bathrooms 1 and 2. The daycare operation hours are Monday to Thursday
from 7:30 AM to 5:30 PM and Friday 7:30 to 4:00 PM.
Licensee applied for relocation on 06/28/2021. Licensee has a current license (#414004312) in San Redwood City.

LPA toured and inspection the house and yard for health and safety hazard. Applicant has a fully charged 2A10BC fire extinguisher, working cellular phone, and working smoke and carbon monoxide detectors in the house. Licensee already moved day-care furniture, some books, toys, and learning material into the house. There is not fireplace in the day-care area. Per licensee, there was no guns and no weapons in the home. Per licensee, she will provide lunch and two snacks for daycare children. LPA discussed with licensee about the IMS and provided a sample to her during the inspection. LPA also discussed with the licensee about the Safe Sleep regulations during the inspection. Applicant’s CPR expires 12/2/22.

Licensee must complete the following items prior the approval:


 Finish moving into home
 Fire Clearance approval.

This report is emailed to licensee with a request for reply demonstrating receipt.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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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