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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420306
Report Date: 07/19/2021
Date Signed: 07/19/2021 12:15:31 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:OLIVARES, NELLYFACILITY NUMBER:
013420306
ADMINISTRATOR:OLIVARES, NELLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 790-9116
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:14CENSUS: 9DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nelly OlivaresTIME COMPLETED:
12:30 PM
NARRATIVE
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On 7/19/2021 at 9:30am, Licensing Program Analyst (LPA) Jonathan Williams met with Licensee, Nelly Olivares, for a Required 1 Year Inspection. Present for this inspection are the Licensee, one fingerprint cleared/associated staff member, and nine children in care (two infants and seven preschoolers). The facility was toured to conduct a health and safety inspection.

The home is a one story home and is tidy and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the play/learning room, hallway bathroom, first room located on the left side of the hallway (infant room), living room, and the dining room. The OFF LIMIT AREAS are the kitchen, master bedroom/bathroom, and the last bedroom located on the right side at the end of the hallway which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA is the living room.

The backyard was toured at 9:45am. Backyard is fenced. There are safe, operable, and age-appropriate toys and learning materials in the backyard. There are no pools, hot tubs, ponds, or any other bodies of water in the on-limits areas during today's inspection. All hazardous materials and toxins were observed to be made inaccessible to children during today's inspection. Per Licensee, there are no firearms kept in the home. There is a fireplace in the home which is barricaded to prevent access to children. LPA observed a child in care under the age of 12 months asleep in a baby bouncer at 9:50am.

The facility has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. Licensee has current CPR/1st Aid training which expires on 09/2021. Licensee and assistant provider have completed the Mandated Reporter Training "Child Care Providers" course. The facility is in ratio today. Children's files and staff files were reviewed for proper documentation at 10:00am. Facility roster was obtained at 10:03am. Facility conducts fire/disaster drills at least once every 6 months.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: OLIVARES, NELLY
FACILITY NUMBER: 013420306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2021
Section Cited

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(10) A baby walker shall not be allowed... in accordance with Health and Safety Code Section 1596.846(b) and (c)... 1596.846(c) A "baby walker" means any article described in paragraph (4) of subdivision (a) of Section 1500.86 of Part 1500 of Title 16 of the Code of Federal Regulations.
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This requirement was not met as evidenced by: Based on LPA observation, a baby bouncer was present in the facility. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
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: OLIVARES, NELLY
FACILITY NUMBER: 013420306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2021
Section Cited

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102425 Infant Safe Sleep (i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.
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This requirement was not met as evidenced by:
Based on LPA observation, a 10-month old infant was left asleep in a baby bouncer. This poses an immediate risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 3 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: OLIVARES, NELLY
FACILITY NUMBER: 013420306
VISIT DATE: 07/19/2021
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS to children at this time. 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 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 that California Law requires licensed 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 624). 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.

Two deficiencies were cited today, including one Type A deficiency, and must be corrected by the due date. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by a licensing representative upon request.

This report shall remain on file for 3 years. A Notice of Site Visit was provided to the Licensee. LPA reminded the Licensee to post the Notice of Site Visit where it is clearly visible inside the facility for 30 days. Appeal rights were provided to the Licensee. Exit interview was conducted at 12:00pm.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4