013421298-10-14-2019-52-CC-DCAS-BGXUFE-20191014153238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421298
Report Date: 10/14/2019
Date Signed: 10/14/2019 03:32:45 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:	FLORES, CONCEPCION		FACILITY NUMBER:	013421298
ADMINISTRATOR:	FLORES, CONCEPCION		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 393-2111
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	14	CENSUS: 8	DATE:	10/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cocepcion Flores		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Diana Campos met with licensee Concepcion Flores for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was fingerprint cleared assistant Alicia Osorio, and 8 children in care which consisted of 4 infants, and 4 preschool age children. The home was toured with the licensee to conduct a Health and Safety Inspection. This is a single story home which consists of 3 bedrooms, 2 bathrooms, living room/ dining room, kitchen, laundry room, fenced backyard and front yard. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are: the living/dining room, kitchen, 2 bedrooms to the right of the hallway, bathroom at the end of the hall way, and the backyard. The OFF LIMIT AREAS are: the master bedroom, and master bathroom, laundry room, and the outdoor storage shed which will be inaccessible by closed and/or locked doors and visual supervision at all times. The ISOLATION AREA is the first bedroom to the right of the hallway (adjacent to living room). The outdoor play area is 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. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working telephone, and fully stocked First Aid Kit. The licensee's CPR and First Aid certificate is current and expires 06/15/2021. There is a fireplace which is barricaded to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year, with the last drill conducted on 09/03/19. Facility and children's files were reviewed and found to be complete. Reviewed and obtained a copy of the facility roster and disaster drill log. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: FLORES, CONCEPCION	FACILITY NUMBER: 013421298
	VISIT DATE: 10/14/2019

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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. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov
There are no deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

LIC809 (FAS) - (06/04)

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