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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010144
Report Date: 12/10/2021
Date Signed: 12/10/2021 03:19:08 PM

Document Has Been Signed on 12/10/2021 03:19 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:CHAVARIN, SANDRA FCCHFACILITY NUMBER:
493010144
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandra ChavarinTIME COMPLETED:
01:52 PM
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A change of location inspection was conducted today by Licensing Program Analyst (LPA) Y. Yang. The licensee was previously licensed at facility number 493008075. The licensee is requesting a license for a capacity of 8 children. Services will be available Monday - Friday, 7:30 AM - 5:15 PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a three bedroom/two bathroom, single level home. There are two adults living in the home. The licensee was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD prior to their initial presence in the home. The licensee 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 living room, kitchen, dining room, mud room, and hallway bathroom. The "off limits" areas include the home's garage, studio, back yard shed, and all its bedrooms (#1, #2, #3). These areas will be made inaccessible by door locks, latches, door knob covers, and/or child 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, will be stored out of the reach of children. There were no firearms and ammunition in the home at the time of this inspection. Licensee states that poisons are stored in the key-locked garden shed in the backyard. 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, carbon monoxide detector and a fire extinguisher rated at least 2-A 10:BC. The licensee stated that the home's wood burning fireplace is not used and is latched. The home's back yard and front yard are fully fenced and will be used for childcare. There is no spa, pool, pond, or fountain on the premises and none shall be added without prior approval from the Licensing agency.

Continued on LIC 809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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: CHAVARIN, SANDRA FCCH
FACILITY NUMBER: 493010144
VISIT DATE: 12/10/2021
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Incidental Medical Services regulations were reviewed with the licensee. The licensee 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. Proof of control of property or landlord notification/consent 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 licensee will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. 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 licensee 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 licensee 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/. Infant safe sleep regulations were discussed with the licensee. The licensee 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.
The change of location application has been approved effective today's date.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC809 (FAS) - (06/04)
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