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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419824
Report Date: 04/20/2023
Date Signed: 04/20/2023 10:16:06 AM


Document Has Been Signed on 04/20/2023 10:16 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:CHAVEZ, MARJORIEFACILITY NUMBER:
013419824
ADMINISTRATOR:CHAVEZ, MARJORIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 680-6510
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 6DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Marjorie ChavezTIME COMPLETED:
10:30 AM
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On April 20, 2023, at 8:15 AM, Licensing Program Analyst (LPA) Elimika Woods met with licensee Marjorie Chavez for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection was the licensee's fingerprint cleared assistant L. Chavez, son G. Chavez Jr. (17), five (5) preschool age children, and one (1) infant. The licensee is in ratio today. Licensee stated that the facility operates from Monday to Friday 5:30 AM to 6:30 PM.

LPA toured the facility inside and outside to conduct a Health and Safety inspection. This single story home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The Isolation area of the home will be a section of the hallway, away from other children in care.

There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection.

The home has a working smoke detector, working carbon monoxide detector, first aid kit, telephone, and a fully charged 3A40BC fire extinguisher which meets standards established by the State Fire Marshal. There's no fireplace or heaters accessible to children in care. Per licensee, there are no firearms in the home. LPA asked the licensee does she transport children and the licensee stated that she does not transport children.

On-limit-areas are the: Living room, dining room, kitchen, bathroom next to hall, playroom and backyard.

Off-limit-areas are the: Left side of the backyard which is inaccessible by a gate/barrier, all three bedrooms, and second garage.

See 809-C for continuance
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAVEZ, MARJORIE
FACILITY NUMBER: 013419824
VISIT DATE: 04/20/2023
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The OUTDOOR PLAY area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. During today's inspection, there are no play structures which are required to be anchored. The left side of the backyard is off limits which is made inaccessible by a barrier.

At 9:00 AM LPA requested and reviewed the files of three (3) children in care. All children files contain Immunization, Parent's Rights, and Medical Consent forms. The facility roster was reviewed, and copies were obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 07/13/22. The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 11/2023. The licensee has completed mandated reporter training on 01/25/2022. The licensee is in compliance with the immunization laws which pertains to all childcare providers. All required forms are posted and visible for public review.

Effective August 1, 2003 California Law requires Family Child Care Home 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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



See 809-C
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAVEZ, MARJORIE
FACILITY NUMBER: 013419824
VISIT DATE: 04/20/2023
NARRATIVE
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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.

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.

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/inspection-process.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Marjorie Chavez.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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