013410104-8-30-2019-52-CC-DCAS-BFJP2L-20190830105608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013410104
Report Date: 08/30/2019
Date Signed: 08/30/2019 10:56:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	PEREIRA, FRANSKIN		FACILITY NUMBER:	013410104
ADMINISTRATOR:	PEREIRA, FRANSKIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 481-9937
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	12	CENSUS: 3	DATE:	08/30/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Franskin Pereira		TIME COMPLETED:	11:15 AM

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	On 08/30/19 at 9:15am Licensing Program Analyst Diana Campos met with licensee Franskin Pereira for an UNANNOUNCED RANDOM VISIT. Present for this visit was 3 preschool age children. The home was toured with licensee to conduct a Health and Safety Inspection. This is a single story home which consists of a living/dining room, 3 bedrooms, a play room, bathroom, kitchen, back yard and detached garage. The home is neat and clean with heating and ventilation for safety and comfort. The areas used for day care are the living/dining room, play room, bathroom, bedroom next to bathroom, bedroom across hallway from bathroom., and the back yard. The OFF LIMIT AREAS are bedroom at end of hallway, kitchen, detached garage, and storage shed in the back yard which will be inaccessible by closed and/or locked doors and visual supervision at all times. The ISOLATION AREA will be in the living room. The outdoor play area is the fully fenced back yard which is free from defects or dangerous conditions. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible during today's inspection. The home has a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide combination detector, working telephone, and fully stocked First Aid Kit. The licensee CPR and First Aid certificate is current and expires 03/10/2020. The heaters and/or fireplace are screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one recorded on 03/18/19. Children's files were reviewed and found to be complete. Reviewed and obtained a copy of the facility roster and disaster drill log. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PEREIRA, FRANSKIN	FACILITY NUMBER: 013410104
	VISIT DATE: 08/30/2019

NARRATIVE

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Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov
Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies provided to licensee.

There are no deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019

LIC809 (FAS) - (06/04)

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