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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911696
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:21:43 PM

Document Has Been Signed on 04/07/2022 12:21 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CHAVEZ, LLOBANA FAMILY CHILD CAREFACILITY NUMBER:
503911696
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Llobana ChavezTIME COMPLETED:
12:30 PM
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On 04/07/2022 a planned Pre-licensing inspection was made today by Licensing Program Analyst (LPA) Rene Mancinas, who met with Applicant, Llobana Chavez. A tour of the home, inside and outside, as shown on the facility sketch was done. This is a single-story home. The areas of the home that day-care children will have access to are the living room, dining room, kitchen, family room, hallway restroom, and a portion of the backyard designated for daycare use. The remainder of the home is off limits and made inaccessible by child safety devices (i.e. safety latches and/or plastic doorknob spinners and/or safety gates). Applicant and three other adult are the only adults that reside in the home. The LIS 536 was signed indicating that the adults living in the home and/or providing care and supervision to children are background cleared. LPA observed safe indoor play areas, child safety plugs in unused electrical outlets, were all observed. Fire extinguisher, smoke detectors, carbon monoxide detectors and first aid kit are operable and in place. There are no firearms or ammunition at the home. CPR, first aid training, and health and safety training are current and expiring 06/28/2023. Child Abuse Mandated Reporter Training Completed 06/02/2021. LPA discussed the practice of fire and disaster drills at least every 6 months and to document the date, time and number of children present. There are pets at this home. Applicant understands the responsibility of any action taken by pets involving day care children.

Incidental Medical Services (IMS) policy were discussed. 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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, available at: http://www.ada.gov/childqanda.htm

(Continued on 809-C)

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Rene Mancinas
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: CHAVEZ, LLOBANA FAMILY CHILD CARE
FACILITY NUMBER: 503911696
VISIT DATE: 04/07/2022
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Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-andresources/safe-sleep as an additional resource. LPA also informed applicants 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.

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 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.

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. Planned hours of operation are Monday through Friday from 08:00AM - 06:00PM, and as arranged

The following items are pending and/or need to be corrected prior to licensure for a small Family Child Care Home, capacity of eight children * ages under 18 years* to be granted. License effective date to be determined based upon below corrections completed and a second in-person inspection conducted by Department staff.

1. Applicant is to install a pool fencing which meets fencing regulation requirements. (Regulation requirements/specifics provided to applicant.

Exit interview conducted and report was reviewed with the applicant.
This report shall be made available to the public upon request.
To order forms, etc. visit our website at www.ccld.ca.gov
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Rene Mancinas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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