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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009967
Report Date: 09/01/2021
Date Signed: 09/02/2021 03:06:19 PM

Document Has Been Signed on 09/02/2021 03:06 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:LIZARDI, BETZAIRA FCCHFACILITY NUMBER:
493009967
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Betzaira LizardiTIME COMPLETED:
03:35 PM
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A required - 1 year inspection was made to the facility by Licensing Program Analysts (LPA) Leticia Rosales-Meza. A review of staff records on 09/01/21 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home.
During today’s inspection the home and grounds were toured. The licensee was supervising one preschool child, and one infant, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 5:00 AM to 6:00 PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The "off limits" areas of the home is the entire second floor, living room, formal dining, and garage, which were made inaccessible by safety gates, door knob covers, and key locked door. The home was clean and orderly, and was at a comfortable indoor temperature of 70 degrees Fahrenheit. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 04/2022. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Latches and Tot locks are used on kitchen cabinets. Poisons are stored in the garage, using a key lock. There is a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2-A, 10:BC. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the back yard as the outdoor play area and it is fully fenced. No bodies of water were observed. Two children's (C1 and C2) records were reviewed at 3:15 PM; required emergency information was observed to be on file. The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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. (Continue to LIC 809-C)
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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: LIZARDI, BETZAIRA FCCH
FACILITY NUMBER: 493009967
VISIT DATE: 09/01/2021
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The following information regarding ADA was provided: US Department of Justice 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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