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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073404524
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:56:07 PM


Document Has Been Signed on 05/16/2023 12:56 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CUSTODIO-NOMELLINI, CARMENFACILITY NUMBER:
073404524
ADMINISTRATOR:CUSTODIO-NOMELLINI, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 934-8396
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:14CENSUS: 9DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Carmen Custodio-NomelliniTIME COMPLETED:
01:30 PM
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On 5/16/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Required 1 Year Inspection at Carmen Custodio-Nomellini Family Child Care Home. LPA met with Licensee, Carmen and explained the purpose of today’s inspection. Present in the home were Licensee, one Assistant and nine (9) day care children (1 infant, 8 preschoolers). Facility is in compliance with required ratios today. Other adults present in the home were Licensee's son and a visiting relative. Adults have Criminal Background Check Clearances. Days/hours of operation are Monday-Friday from 7:30am-5:30pm.
INDOOR space was inspected. It is a single floor home. Entrance to day care is through the right side yard gate
IN USE AREAS: Classroom (converted garage), half bathroom, Family room, Hallway from Play room to family room, Side yard and Backyard
OFF LIMIT AREAS: Kitchen, Living room, Dining area, 3 bedrooms, Office, 2 bathroom, laundry closet, Left side yard, storage shed.
LPA observed sufficient materials, toys, and play equipment. Children were engaged in various activities under the supervision of the Licensee. All detergents, cleaning compounds, medications, and other similar items were inaccessible to children. Furniture and equipment were age appropriate and in good condition. There were no baby walkers, jumpers or bouncers observed during inspection. The home is sanitary, orderly and safe. There is a fireplace in off limit area. No stairs in the home. LPA observed a fully charged fire extinguisher that meets State Fire Marshal standards and working smoke/carbon monoxide detectors. There are no pets in the home. LPA reviewed a current Children Roster, Emergency Disaster Plan LIC610A. All required postings were observed posted on a wall. Licensee states she does not transport children. She provides snacks and children bring their own lunch. Food storage area was observed to be clean.
OUTDOOR space was inspected. Play equipment was observed in safe condition and free of hazards. Heavy structure was secured to the ground. The yard was fenced and there were no bodies of water observed.
FILE REVIEW: Children, Licensee, Assistant files were reviewed. Mandated Reporter Training and certifications for CPR/First Aid are current.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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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: CUSTODIO-NOMELLINI, CARMEN
FACILITY NUMBER: 073404524
VISIT DATE: 05/16/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
Supervision of children was discussed, and Licensee understands that she must be present in the home during 80% of the operating hours and ensure children are supervised at all times.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the Safe Sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

In the areas that were evaluated, no regulatory violations were observed. LPA discussed and provided technical assistance on child/staff records, roster, fire drills. LPA provided LIC311D Forms/Records to be kept in facility.
Exit interview conducted and report was reviewed with the Licensee, Carmen Custodia-Nomellini. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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