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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415933
Report Date: 12/02/2019
Date Signed: 12/02/2019 03:08:46 PM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:MAYORGA, MARIAFACILITY NUMBER:
013415933
ADMINISTRATOR:MAYORGA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 532-4906
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:14CENSUS: 9DATE:
12/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria MayorgaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Diana Campos met with the licensee for an unannounced random inspection. Present during this inspection were fingerprint cleared assistant Maria Garcia and 9 children in care which consisted of 2 infants, and 7 preschool age children. The home was toured with licensee to conduct a Health and Safety Inspection.
This is a tri-level home, which is neat and clean with heating and ventilation for safety and comfort. The on limit areas are the living room, dining room, kitchen, play room and bathroom on the lower level, and art room in the backyard. The off limit areas are inaccessible by gate, 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 fenced and 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 during today's inspection.
The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide detector telephone, and fully stocked First Aid Kit. The licensee's, and assistant's CPR and First Aid certificates are current and expire 03/23/2021. The heaters and fireplace are screened to prevent access by children. There is a gate at the top and bottom of stairs to avoid access by children. Per licensee, there are no firearms in the home. Children's files were reviewed. The facility roster was reviewed, and a copy obtained. All required forms are posted and visible for public review. Safe sleep practices were discussed.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2019
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MAYORGA, MARIA
FACILITY NUMBER: 013415933
VISIT DATE: 12/02/2019
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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.

LPA verified that the licensee has completed the required mandated reporter training on 2/24/18.

There are no deficiencies cited. This report shall remain on file for 3 years. A Notice of Site visit was given to Licensee, and Licensee was reminded that it is required to be posted for 30 days. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2019
LIC809 (FAS) - (06/04)
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