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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418031
Report Date: 11/10/2021
Date Signed: 11/10/2021 11:25:34 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:CAMACHO, MIREYA SOSAFACILITY NUMBER:
013418031
ADMINISTRATOR:CAMACHO, MIREYA SOSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 512-3759
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:14CENSUS: 5DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Mireya Sosa CamachoTIME COMPLETED:
11:23 AM
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On 11/10/2021 at 9:10am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Mireya Sosa Camacho for an Unannounced Annual Inspection. Present during the inspection was the Licensee and her fingerprint cleared helper Y. Duenas Diaz. There was one (1) infant and four (4) preschool children present during the inspection. Licensee’s home was toured for a health and safety inspection. The facility operates 8:00am – 5:00pm, Monday - Friday.

ON LIMITS AREA: Two (2) Playrooms next to the converted Garage, Master Bedroom and Bathroom and Front Yard


OFF LIMITS AREA: Main House: Three (3) bedrooms, Kitchen, Living Room, one (1) bathroom. Converted Garage: Bedroom, Bathroom, Eat-in Kitchen and Back Yard
ISOLATION AREA: Master Bedroom

The facility is a single-story home owned by the Licensee. The inside of the home is observed to be neat and clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas.

The home has one (1) fully charged 3A40BC fire extinguisher in the first playroom. There is one (1) working smoke detector and one (1) working carbon monoxide detector in the first playroom. The home is equipped with central heat and air for proper ventilation. LPA did not observe and bodies of water in or around the home that could be a potential danger to the children in care. Licensee stated that there are no firearms and two (2) dogs in the home.

Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CAMACHO, MIREYA SOSA
FACILITY NUMBER: 013418031
VISIT DATE: 11/10/2021
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The Licensee’s Health and Safety training with Lead poisoning has been completed and CPR and First Aid training is complete with an expiration date of 10/2022. Helpers CPR and First Aid training expires in 5/2023. Licensee Mandated Reporter training is valid and expires on 6/2/2023. Helpers Mandated Reporter training expires on 6/7/2023. All required forms are posted and visible for public view in the playroom. LPA obtained the children’s files and the facility roster. All files are complete. LPA obtained the fire/disaster drill log. Log is complete with the last drill logged 5/19/2021.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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


Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CAMACHO, MIREYA SOSA
FACILITY NUMBER: 013418031
VISIT DATE: 11/10/2021
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Mireya Sosa Camacho.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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