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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010129
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:40:30 PM

Document Has Been Signed on 11/09/2021 02:40 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLEVELAND, CRYSTAL FCCHFACILITY NUMBER:
483010129
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Applicant Crystal ClevelandTIME COMPLETED:
02:50 PM
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An announced prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Elpidia Hernandez Torres. The applicant is requesting a license for a capacity of 8 children. Services will be available Sunday- Saturday, 05:00 AM - 11:00 PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a two story, five bedroom home. There are presently three adults living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.

The floor and yard plans are verified. The children will have access to the entire 1st floor which includes; child care room 1 (front living room), kitchen, child care room 3, child care area 2 (dining room), bathroom, back patio and kids play yard. The "off limits" areas include the entire 2nd floor, the garage, the remainder of the backyard. These areas were made inaccessible with child safety gates, door knob slip covers, and door locking mechanisms . The applicant stated that the fireplace is not in use, it is barricade with fire place screen and child safety gates. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. The applicant stated that there are no firearms or ammunition stored on the premises. Applicant stated there are no poisons stored on the premises. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies will be maintained at the facility. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector and has a fire extinguisher rated at least 2-A 10:BC.The home's main backyard is fully fenced. One of the home's side yard is off limits to day care children. There is no spa, pool pond, fountain or other body of water on the premises. None shall be added without prior approval from the Licensing agency.

Continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129
VISIT DATE: 11/09/2021
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Incidental Medical Services (IMS) regulations were reviewed with the applicant. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department.

Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Parent's rights poster will be posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The licensee will maintain current pediatric CPR and First Aid certification. The licensee shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in any area where child care is provided. The licensee understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/. Megan's Law web site was provided(http://www.meganslaw.ca.gov). The AAP Guide to Safe Sleep Practices and the Effects of Lead Exposure brochures were provided and reviewed with the applicant. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

This facility has been approved for licensure effective today's date.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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