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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403767
Report Date: 06/20/2023
Date Signed: 06/20/2023 11:14:09 AM


Document Has Been Signed on 06/20/2023 11:14 AM - 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:SANDOVAL, LYDIAFACILITY NUMBER:
073403767
ADMINISTRATOR:SANDOVAL, LYDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 565-2021
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:14CENSUS: 0DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lydia SandovalTIME COMPLETED:
11:00 AM
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On 06/20/2023 at 8:50 AM, Licensing Program Analyst (LPA) Christina Watts conducted a Case Management - Incident at Lydia Sandoval's large family home. LPA explained the purpose of this inspection. During today's inspection, there were no children in care and there are 10 children enrolled. Licensee was present during inspection. All adult living in the home have Criminal Record Clearance.

LPA is following up on a self report incident that was submitted to licensing on June 12, 2023. Licensee reported that a child was pushed off the bed. On June 9, 2023, Licensee stated that she was in the room with C1, C2, and C3 when the licensee turns their back to get a book when C1 pushed C2 off the bed. Licensee stated they turn around and seen C2 on the floor when C1 jumped on the floor and grabbed C2 by their arm. Licensee stated they separated C1 from C2. Licensee stated that they scooped up C2 and took C2 to the living room. Licensee stated they called C1 and C2 parents and the parent came to the facility to pick up the children. Licensee stated that C1's elbow was broken and that a procedure was done the same day. Licensee stated C1 returned to the facility on June 13 or June 14. Licensee stated they removed the bed from the room. LPA observed the room and did not observe a bed in the room.

Licensee followed regulations in regards to contacting parent when child sustained injury in the facility as well as informing licensing about incident within 24 hours of incident. Licensee also removed the bed from the room and the room is empty besides a TV and books. Also, licensee was inside the room when the incident occurred and quickly assisted C2 when C2 was injured.

During today's inspection, no deficiencies have been cited. Exit interview conducted and report was reviewed with the licensee, Lydia Sandoval. A notice of site visit was given and must remain posted for 30 consecutive days.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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