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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911248
Report Date: 06/03/2021
Date Signed: 06/04/2021 10:34:19 AM

Document Has Been Signed on 06/04/2021 10:34 AM - 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:COSTA, CHELSIE FAMILY CHILD CAREFACILITY NUMBER:
543911248
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
06/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Chelsie CostaTIME COMPLETED:
12:15 PM
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On 6/3/2021, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced annual inspection and met with Licensee, Chelsie Costa. Costa's fiance Frank Martinez, was also present. A tour of the home was conducted. Business hours are Monday through Friday 7:30 AM to 5:30 PM.
Current facility sketch reviewed. Licensee confirmed the living room, dining room, kitchen, hall bathroom and day-care room are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of spinner knobs. The fireplace located in the living room was made inaccessible to children by a glass door and will not be used during day care hours. The home was kept clean and orderly, with heating and ventilation for safety and comfort. There were no stairs in the home. Safe toys and play equipment were observed. Licensee had a working telephone and the above telephone number was verified.
Medications and other hazardous items were inaccessible to children. LPA did not observe any poisons in the home. Poisons were locked per regulation. The fire extinguishers, smoke detectors, and carbon monoxide detector met Community Care Licensing (CCL) regulations.
The outdoor play area in the backyard is fenced and there are no hazards to day care children. Licensee ensures that children in care are supervised at all times. There was no swimming pool, bodies of water, or firearms on the premises.
Licensee is aware children shall not be left in parked vehicles and is aware car seats are used for transportation purposes only and are not used for sleeping children.
There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with Licensee. There is one play yard for each infant in care. The play yards are kept free from all loose articles and objects while infants are sleeping. There are no objects hanging above or attached to the play yard. Infants in care are not swaddled. Licensee physically checks on sleeping infants every 15 minutes and documents any signs of distress, to include but is not limited to: flushed skin color, increase in body temperature, restlessness, and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. An Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age and those infants are placed on their backs for sleeping.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, CHELSIE FAMILY CHILD CARE
FACILITY NUMBER: 543911248
VISIT DATE: 06/03/2021
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A sample of children’s records contained all emergency information specified by regulation. There were no excluded individuals present at this home. All adults who reside or work in the home had a criminal record clearance or exemption. A review of records indicated Licensee and her fiance have proof of required immunization and/or written declaration declining flu shot. Licensee's Mandated Reporter Training was completed on 1/6/2020. Licensee's pediatric CPR and First Aid expires on 10/22/2021.
Adequate supervision was being provided during this inspection and capacity as specified on the license was being maintained.
Incidental Medical Services (IMS) are not currently provided. Licensee is aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA information line at (800) 514-0301 (voice), (800) 514-0383 (TDD), and website link: https://www.ada.gov/childqanda.htm. http://www.ada.gov/childqanda.htm

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms, and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations no deficiencies were observed today.
Exit interview was conducted with Licensee and she was provided a copy of the Facility Evaluation Report (LIC 809) and the Notice of Site Visit form (LIC 9213).

The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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