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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911581
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:55:17 PM

Document Has Been Signed on 08/20/2021 02:55 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:DIAZ, ANA FAMILY CHILD CAREFACILITY NUMBER:
543911581
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
08/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ana Diaz, Spanish SpeakerTIME COMPLETED:
02:55 PM
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On 08/20/2021 A planned Prelicensing inspection was made today by Licensing Program Analyst (LPA) Daniel Alvarez, who met with Applicant Ana Diaz. A tour of the home, inside and outside, as shown on the facility sketch was done. The areas of the home that day care children will have access to are the living room, dining room, and hall bathroom. Background clearances were reviewed and verified. Applicant, her husband, her mother-in-law, and three minor children live in the home. The LIS 531 was signed indicating that the adults living in the home and/or providing care and supervision to children are background cleared. LPA observed safe toys, safe indoor and outdoor play areas, child safety plugs in unused electrical outlets, child safety latches on cabinets and/or cabinets with safe items, and a clean and orderly home were all observed. Fire extinguisher, smoke detectors, carbon monoxide detector, and first aid kit are operable and in place. Off-limits rooms are made inaccessible by children safety plastic door knobs, and child safety gate. Applicant stated there are no firearms in this home, nor did LPA observed this item. There is a in-ground Koi pond located on the property that is not fenced per title 22 regulations. CPR, first aid training and health and safety training are current expiring 03/19/2023. Postings, forms, and immunization cards were provided and discussed. 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. Applicant does not have any pets. Fact Sheet for Assembly Bill 633 - Child Care Parent Notification Requirements was discussed and copies were provided to applicant - (Fact Sheet and LIC 9224 -Acknowledgement of Receipt of Licensing Reports), The current LIC 995A (12/06) Notification of Parent's Rights and Pub 394 (12/06) -Notification of Parents Rights poster were also provided.
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Daniel Q Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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 2
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: DIAZ, ANA FAMILY CHILD CARE
FACILITY NUMBER: 543911581
VISIT DATE: 08/20/2021
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Incidental Medical Services (IMS) policy was 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

Before Licensure the following items are to be corrected to avoid the application form being withdrawn:

1. Applicant needs to bring her in-ground Koi pond fence within title 22 regulation regarding accessible bodies of water. Currently the diameter of the holes on the chain link fence are more that 1 3/4 inches. The gate is not self-closing and or self-latching, nor opens away from the body of water. Lastly the latching mechanism is not at least 54"inches from the ground.

Pending verification of corrections and a final review of your application, licensure as a Small Family Child Care Home capacity of eight children* ages under 18 years, will be recommended. Planned hours of operation are Monday through Friday from 4:30AM - 5:30PM.

A copy of this report is to remain in the facility for public review.
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: Duane Matsubara
LICENSING EVALUATOR NAME: Daniel Q Alvarez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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