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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422085
Report Date: 02/01/2023
Date Signed: 02/01/2023 12:52:06 PM


Document Has Been Signed on 02/01/2023 12:52 PM - It Cannot Be Edited

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:AYCHILUHIM, HIRUTFACILITY NUMBER:
013422085
ADMINISTRATOR:AYCHILUHIM, HIRUTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 228-8367
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:14CENSUS: 3DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Hirut AychiluhimTIME COMPLETED:
01:18 PM
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Licensing Program Analyst Sidney Cortez, met with licensee for Hirut Aychiluhim for an UNANNOUNCED ANNUAL RANDOM, Health and Safety Inspection. Present for this visit was the licensee, 2 infants and1 preschooler (3 total children). Licensee is within capacity limits. The hours of operation are 7:00AM- 5:30 PM, Monday -Friday.The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:00AM until 6:00 PM, MONDAY-FRIDAY. This is two story house consists, 6 bedrooms and 3 bathrooms, 2 kitchens, Garage and backyard. Entry into the childcare area is through the side of the home, through the gate.


On-limit-areas are : Downstairs level: Living/Play room, 3 bedrooms, 1 bathroom and back yard.
Off Limit areas are: Entire upstairs, Downstairs kitchen and garage. Isolation area: is one of the bedrooms that is on limits 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 .Per licensee, there are no firearms in the home. The home has a working smoke detector, carbon monoxide detector, working telephone, and First Aid Kit. The home has a fully charged (3A40BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone.

The licensee CPR and First Aid certificate is current and expires (July 2023). The licensee's mandated reporter is current and will expire in March 2024. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on January, 2023.. 2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809C for Continuation
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney CortezTELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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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