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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415602
Report Date: 04/10/2024
Date Signed: 04/10/2024 09:17:48 AM


Document Has Been Signed on 04/10/2024 09:17 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MEDINA, TINAFACILITY NUMBER:
013415602
ADMINISTRATOR:MEDINA, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 706-1941
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:14CENSUS: 3DATE:
04/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Tina MedinaTIME COMPLETED:
11:04 AM
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Licensing Program Analyst Sidney Cortez, met with licensee Tina Medina for an Unannounced Annual Random Inspection. Present for this visit was the licensee Tina Medina and (3) pre school age child. The rest of the children are in school. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 4:30AM until 6:30PM, MONDAY-FRIDAY. The home is a single story home which is neat and clean with heating and ventilation for safety and comfort. The on limit areas are the living room, kitchen, dining room, play room and bathroom near the play room. Backyard is on limits, but currently not using due to storm. The off limit areas are the 3 bedrooms and garage-- inaccessible by closed and/or locked doors and visual supervision. The isolation area will be a section of the living room, away from other children in care. The outdoor play area 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.


LPA did not observe any toxins or hazardous items accessible today.The heaters and/or fireplace are screened to prevent access by children. Per licensee, there are no firearms in the home. The home has a working smoke detector, carbon monoxide detector, working telephone, and First Aid Kit.


The home has a fully charged (2A10BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone. The licensee CPR and First Aid certificate is current and expires (January 20, 2025). The licensee's mandated reporter training is complete which will expire in Feb 2025. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on Jan 2024. .2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney CortezTELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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