013421887-10-17-2019-02-CC-CCON-BH2VL4-20191017163120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421887
Report Date: 10/17/2019
Date Signed: 10/17/2019 04:31:28 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	CORDOVA, MERCEDES		FACILITY NUMBER:	013421887
ADMINISTRATOR:	CORDOVA, MERCEDES		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 891-1440
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	14	CENSUS: 6	DATE:	10/17/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:19 PM
MET WITH:	Mercedes Cordova		TIME COMPLETED:	05:00 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 Caroline Colson met with Mrs. Mercedes Cordova, her husband, Humberto Cordova, and her teenage daughter for an unannounced random annual inspection at 2:16 PM. One (1) child's record was reviewed by the LPA and the licensee on 10/17/19 at 2:56 PM. C1 has a complete file. There are three (3) infants and (3) preschool children present. The home was toured to conduct a health and safety inspection. The home is a two story home. The home consists of a downstairs living room, kitchen, 1 downstairs bedroom, 1 1/2 downstairs bathrooms, 3 upstairs bedrooms, 1 1/2 upstairs bathrooms, upstairs living room, double car garage, enclosed side yard, laundry room and fenced back yard. The laundry room, 1 downstairs bathroom, kitchen, 3 upstairs bedrooms, 1 upstairs living room, 1 1/2 upstairs bathrooms and garage are the off limit areas. The home has 2A10BC fire extinguisher and a combination smoke and carbon detector. Mrs. Cordova states that there are no firearms. The isolation area is the downstairs bedroom. Pediatric First Aid and CPR certificates are current and expires on April 7, 2020. First Aid Kit is available and complete. Mrs. Cordova had an additional yard built in her home. The fenced side yard is adjacent to the living room and will be used for outdoor play. There are no pets. This facility is not providing Incidental Medical Services-IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417. Please See LIC 809 C for additional information

SUPERVISOR'S NAME: Ann Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline Colson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CORDOVA, MERCEDES	FACILITY NUMBER: 013421887
	VISIT DATE: 10/17/2019

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REMINDERS/RESOURCES

· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

The childcareadvocatesprogram@dss.ca.gov is the email address for the applicant to sign up to receive PINS.

Analyst discussed Best Sleep Practices for Infants, updating required forms and tightly securing the barricade for the stairs leading to the second level.

A site notice was posted. An exit interview was conducted. Appeal rights were discussed and given. This report must remain available for public review for 3 years.

There were no deficiencies cited during this inspection.

SUPERVISOR'S NAME: Ann Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline Colson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019

LIC809 (FAS) - (06/04)

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