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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010601
Report Date: 03/01/2024
Date Signed: 03/01/2024 02:32:41 PM

Document Has Been Signed on 03/01/2024 02:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CLEVELAND, CRYSTAL FCCHFACILITY NUMBER:
483010601
ADMINISTRATOR:CLEVELAND, CRYSTALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 725-1213
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 0DATE:
03/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Crystal Cleveland - ApplicantTIME COMPLETED:
02:45 PM
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A Pre-licensing inspection visit was conducted today by Licensing Program Analyst (LPA), Melchisedeck Augustin for the purpose of changing the facility’s location. The applicant requested a license for capacity of 14, and services will be provided Monday - Friday; 5:00 a.m. – 9:00pm. The facility was granted a fire clearance by the local fire department on 02/20/24. The applicant understands that childcare must be provided in the "primary" residence of the applicant. The residence is a four bedroom/three bath home. There are three adults and four minor(s) living in the home. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance.


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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The floor and yard plans are verified. The four bedrooms and two bathrooms on the second floor, kitchen, living and dining areas, and garage are off limits to the children. These areas were made inaccessible by means of children’s safety gates and latching mechanism. The children will have access to the family and dining areas, one bathroom, and the backyard. The staircase near the front entrance was barricaded with a retractable child safety gate. The fireplace in the family room was screened with a large white board, and according to the applicant, she did not plan to utilize the fireplace during the facility’s operating hours. The home appears to be clean and orderly at this time and will remain so during childcare hours. There is a working telephone at the facility and the applicant understood the phone is to remain at the facility during the facility’s operating hours. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010601
VISIT DATE: 03/01/2024
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The sharp knives, medicines, are stored out of the reach of children. The knobs on the stove are inaccessible.

The applicant stated she did not store any firearm(s) or other dangerous weapon(s) on the premise. The children in care will have access to age-appropriate toys and equipment. The home is equipped with a working smoke and carbon monoxide detectors, and a fully charged fire extinguisher which met standards and requirements of the State Fire Marshall. LPA did not observe any baby walker(s) on the premise. The applicant stated she currently had one infant under 24 months old enrolled in care and the there was one play yard available. There is no pool, spa, pond, fountain, nor any other source of water accessible to the children, and none is to be added without prior notification and approval of the licensing agency.


Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional childcare liability insurance. The applicant provided proof of control of property.

The applicant’s AB 1207 Mandated Reporter Training certificate is on file. Parent's rights are 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 applicant will maintain current on Pediatric CPR and First Aid. The applicant 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 understand that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. 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 during the hours of operation in those areas where children are present. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010601
VISIT DATE: 03/01/2024
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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) or (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 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 applicant 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.



During the exit interview, the applicant, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. On this date, 03/01/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Megan's Law web site was provided (http://www.meganslaw.ca.gov). The applicant understand that any authorized employee of the Department may enter and inspect the facility with or without advance notice. Applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. LPA consulted on 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. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010601
VISIT DATE: 03/01/2024
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The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family childcare home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/.


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 platforms. 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.

Any proposed changes to the physical plant, telephone number, or change of mailing address shall be immediately reported to the Department. Exit interview conducted and report was reviewed with the applicant, Crystal Cleveland. The facility is granted approval for a Large Family Child Care Home (FCCH) license, effective, 03/01/24.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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