<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010373
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:17:22 PM

Document Has Been Signed on 05/11/2023 04:17 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:ESQUIVEL, LISSETTE FCCHFACILITY NUMBER:
493010373
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/11/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lissette EsquivelTIME COMPLETED:
12:43 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Y. Yang. The applicant is requesting a license for a capacity of 08 children. Services will be available Mon- Fri 07:30 AM - 05:00 PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a three bedroom/ one bathroom, single level home. There is currently one adult 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 living room,dining room, hall bathroom and bedroom #1. The "off limits" areas of the home are the garage, kitchen area, and bedrooms #2 and #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 (applicant's cell phone). The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. The applicant states there are no firearms and ammunition stored on the premises. Poisons are locked in a 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 and a fire extinguisher rated at least 2-A 10:BC. The children will have access to a fully fenced portion of the backyard. There is a wood play structure with sufficient wood chip cushioning in the backyard. There is no spa, pool, pond, or fountain on the premises and none shall be added without prior approval of the Licensing agency.

Continued on LIC 809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ESQUIVEL, LISSETTE FCCH
FACILITY NUMBER: 493010373
VISIT DATE: 05/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Incidental Medical Services 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. 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. 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 applicant 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 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.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage athttps://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. (Continued on LIC809-C)
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ESQUIVEL, LISSETTE FCCH
FACILITY NUMBER: 493010373
VISIT DATE: 05/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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/. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. Exit interview conducted and report was reviewed with the applicant, Lissette Esquivel.

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 license-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 address shall be immediately reported to the Department.



This small FCCH application is approved effective 05/11/2023
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3