013421103-7-7-2021-52-CC-MPRE-C4PN5S-20210707101001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421103
Report Date: 07/07/2021
Date Signed: 07/07/2021 10:10:06 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:	RIVERA, TILLIE		FACILITY NUMBER:	013421103
ADMINISTRATOR:	RIVERA, TILLIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 825-8075
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	14	CENSUS: 0	DATE:	07/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Tillie Rivera		TIME COMPLETED:	10:10 AM

NARRATIVE

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On 7/07/2021 at 9:20am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Tillie Rivera for an unannounced annual inspection. Present during the inspection was licensee Tillie Rivera. Licensee lives with her fingerprint cleared husband David Rivera and her fingerprint cleared daughters Selena Garcia-Rivera and Merzedes Rivera. There were no children present during the inspection. The Licensee’s home was toured for a health and safety inspection. The operating hours are 5:00am – 6:00pm Monday – Friday.

ON LIMITS AREA: Living Room, Kitchen, Bedroom #4, Bathroom and Backyard

OFF LIMITS AREA: Room #3, Room #2, Bedroom #1, and garage
ISOLATION AREA: Bedroom #4

The facility single story home rented by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms and one dog.

The home has one (1) fully charged 3A40BC fire extinguisher located in the Dining Room. One (1) working carbon monoxide detector in the hallway and Bedroom #1. One (1) smoke detector is located in the hallway, two (2) in the living room and one (1) in Bedroom #1. The home is equipped with central heat and plenty of working windows for proper ventilation. LPA observed no bodies of water in or around the home.

Since Licensee does not have any children enrolled, there are no files. The Licensee’s Health and Safety training has been completed and CPR and First Aid training will be renewed by 7/24/2021. All required forms are posted and visible for public view in Bedroom #4.

Cont on 809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

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: RIVERA, TILLIE	FACILITY NUMBER: 013421103
	VISIT DATE: 07/07/2021

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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 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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 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 $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six 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.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This report was read and given to the Licensee for a signature. There are no deficiencies being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given and must be posted for 30 days.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC809 (FAS) - (06/04)

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