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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403183
Report Date: 01/14/2020
Date Signed: 01/14/2020 09:41:07 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PEREIRA, TATIANAFACILITY NUMBER:
073403183
ADMINISTRATOR:PEREIRA, TATIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 215-0683
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 4DATE:
01/14/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Tatiana PereiraTIME COMPLETED:
10:15 AM
NARRATIVE
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On 01/14/2020, Licensing Program Analyst (LPA), Melissa Guirit, met with licensee Tatiana Pereira for an UNANNOUNCED RANDOM INSPECTION. Present for this inspection were licensee and four infants. The home was toured to conduct a Health and Safety Inspection. The facility's operating hours are from 8:00 AM to 5:30 PM.

The home is two story. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room, kitchen/dining area, bedroom across from the front door (napping room), and right side of the back yard. The OFF LIMIT AREAS are the remainder of the home which will be inaccessible by closed and/or locked doors, safety gate, and visual supervision. There is a safety gate that is placed at the bottom of the stairs that leads to the second level. The ISOLATION AREA will be in the kitchen area. The outdoor play area is free from defects or dangerous conditions and is completely fenced with 100% supervision. There are ample age appropriate toys that appear to be safe and in good condition. Per licensee, the hot tub is on the off limit area of the back yard. 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 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and fully stock First Aid Kit. The licensee's CPR and First Aid certificate is current and expires 05/2021. Licensee completed the Mandated Reporter Training which expires on 03/2020. Licensee is in compliance with immunization law. The fireplace in the living room is screened to prevent access by children and is not in use. Per licensee, there are no firearms in the home. At 9:20 AM, LPA asked for fire drill logs. The licensee has not conducted a fire drill since 2017.

See 809-C for continuance.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2020
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 3
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: PEREIRA, TATIANA
FACILITY NUMBER: 073403183
VISIT DATE: 01/14/2020
NARRATIVE
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(4) 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.

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 .http://www.myccl.gov/

Incidental Medical Services (IMS) policy was discussed.

See 809-D for cited deficiency. 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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PEREIRA, TATIANA
FACILITY NUMBER: 073403183
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2020
Section Cited

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102417(g)(9)(A)(1)Each family child care home sahll conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.
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This was not met as evidenced by: licensee showing LPA fire drill log with the last one documented in 2017.
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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2020
LIC809 (FAS) - (06/04)
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