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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010732
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:22:13 PM

Document Has Been Signed on 08/28/2024 03:22 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ESCOBEDO, MAYRA FCCHFACILITY NUMBER:
493010732
ADMINISTRATOR/
DIRECTOR:
FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:43 PM
MET WITH:Maya EscobedoTIME VISIT/
INSPECTION COMPLETED:
03:31 PM
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A change of location, facility inspection was conducted today by Licensing Program Analyst (LPA) Amy Strother. An application was received to the department on 08/05/2024 for the change of location. The applicant, Mayra Escobedo was previously licensed as a small family child care home, facility number 493010355. The applicant is currently requesting a license for a capacity of 8 children at her new location. Services will be available Monday - Friday, 7:30 AM – 5:30 PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a 5 bedroom/3 bathroom two-story home. There are currently three adults living in the home. 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.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

The floor and yard plans are verified. The children will have access to downstairs rooms, labeled “Kids nap room and “Kids playing area” on LIC999A Facility Sketch and the downstairs bathroom, by way of passing through the living room. The applicant stated that she does not plan to use the living room for care, but will need to pass through it to take children to the bathroom. A diaper changing table was observed in the “Kids nap room”. The living of the home has a sliding door that leads to outdoor space shared by tenants of homes on the property with separate physical addresses. Applicant stated that she will keep the slider locked during child care hours.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ESCOBEDO, MAYRA FCCH
FACILITY NUMBER: 493010732
VISIT DATE: 08/28/2024
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The entire upstairs, kitchen, dining room, office, and two bedrooms downstairs are off-limits, made inaccessible by child safety door knob latches and child safety gates. The upstairs areas consists of a primary bedroom with bathroom and two bedrooms, all off limits with a child safety gate at the bottom of the stairs. 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. The applicant stated there are no guns or dangerous weapons in the home and none were observed. Applicant stated there are currently 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 combination smoke detector/carbon monoxide detector located in the hallway and a fire extinguisher rated at least 2-A10:BC located in the laundry room. The home has it's own yard that is full fenced and will be used for childcare. Applicant understands that children must be supervised at all times while going from the front door of the home into the fenced in yard, and back. The licensee has current pediatric CPR and First Aid certification, which expires 02/2025 and current mandated reporter training, which expires 01/2025.

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 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. 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.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ESCOBEDO, MAYRA FCCH
FACILITY NUMBER: 493010732
VISIT DATE: 08/28/2024
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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/. 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.

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.

On this date, 08/12/2024, 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.

Continue LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ESCOBEDO, MAYRA FCCH
FACILITY NUMBER: 493010732
VISIT DATE: 08/28/2024
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Applicant was informed of the MyChildCarePlan.org site, 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.

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.

This facility is approved for a small FCCH license with a maximum capacity of 8, effective today's date, August 28, 2024.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4