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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073404524
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:51:02 PM


Document Has Been Signed on 03/20/2024 03:51 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: 5DATE:
03/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Carmen Custodio-NomelliniTIME COMPLETED:
04:30 PM
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On 3/20/24 Licensing Program Analyst (LPA) Monica Mathur conducted a Case Management inspection at Carmen Custodio-Nomellini's daycare home. LPA met with Licensee, Carmen and explained the purpose of today’s inspection. Present in the home were Licensee with 5 children (2 infants, 3 preschool age).

Licensee stated she wants to make the Kitchen and Island area off limits to children. Effective today, Off Limits areas are: Kitchen, Island area, Formal Living Room, 3 bedrooms, Office, 2 bathrooms, Dining room, Laundry closet,

LPA discussed Reporting Requirements and provided technical assistance. Technical Violation/Advisory Note was provided. No deficiency was cited today. Exit interview conducted with Licensee, Carmen Custodio-Nomellini. A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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