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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004916
Report Date: 07/05/2022
Date Signed: 07/05/2022 01:08:53 PM

Document Has Been Signed on 07/05/2022 01:08 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:CHAVEZ, MARISOLFACILITY NUMBER:
414004916
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 0DATE:
07/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marisol ChavezTIME COMPLETED:
11:20 AM
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On July 5th, 2022, Licensing Program Analyst (LPA), Leslit Tapia-Mandujano conducted a scheduled Pre-Licensing inspection this day and met with Applicant, Marisol Chavez. Applicant has relocated from Facility #414004745 to this current location. Present in the home today is applicant and adult son. LPA and applicant inspected entire home for Health and Safety Hazards.

Applicant rents home, which is a two bedroom one bathroom house with front and backyard, and garage. Applicant lives in home with three other adults and two minor children. The hours of operation are Monday-Friday from 8am-5pm. Daycare area is: Living Room, Bedroom #1, Bathroom #1, Back yard (portion of the deck) OFF limit areas: Bedroom #2, front yard, driveway, and garage. All off limit areas are properly barricaded.

Licensee is still in the process of moving in. Overall, Day-care is clean, orderly with a variety of age appropriate toys for the children. All furniture inspected is in good repair. The applicant has a fully stocked First Aid kit and thermometer. The home has no pools or bodies of water in the home. There are no pets in the home. Per applicant, there are no guns or weapons in the home. The home has age appropriate equipment available for children in care. Applicant was reminded baby walkers, bouncers, jumpers and any other similar items are to not be used for children in care. Discipline policy was discussed. Isolation area will be bedroom #1.

The home has sufficient lighting and ventilation. Applicant states they will conduct an emergency drill once every six months and log drills. Applicant's CPR & First Aid expire on 12/2023. Mandated Reporter Training Certificate for applicant expire on 07/2024.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAVEZ, MARISOL
FACILITY NUMBER: 414004916
VISIT DATE: 07/05/2022
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LPA discussed the safe sleep regulations with applicant and 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted
Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

During todays inspection, LPA received the following documents: Mandated Reporter Certificate, Preventative Health Certificate, LIC 279B, Lease Agreement, and CPR & First Aid Certificate.

LPA will recommend licensure for Small Family Child Care License once the following is submitted:
*Pictures of Day Care Area set up
*Fireplace Barricaded

Exit interview conducted and report was reviewed with the applicant, Marisol Chavez.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC809 (FAS) - (06/04)
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