073406463-11-5-2019-02-CC-PPEN-BHMTDC-20191105133808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073406463
Report Date: 11/05/2019
Date Signed: 11/05/2019 01:38:22 PM

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:	CHOZOM, DOLMA		FACILITY NUMBER:	073406463
ADMINISTRATOR:	CHOZOM, DOLMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 965-1420
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY:	14	CENSUS: 5	DATE:	11/05/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Dolma Chozom		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Paul Petersen conducted an unannounced random annual site inspection for this facility at 1205 on 11/5/19. LPA met with licensee, Dolma Chozom, and toured all areas of the facility which are on limits to children in care. Also present at the time of this inspection was assistant, Sofia Vargas, and five children in care consisting of four infants and one preschool age child. The facility is within ratio and capacity and all adults present are background cleared. The on limits areas for children in care are the dining area, the play room, the nap room and the hall bathroom. Furnishings, and equipment, including infant sleeping equipment, are age appropriate and free of observed sharp/broken pieces. There were no hazardous items/toxins observed to be accessible to children in care. The facility has heating and ventilation and a portable available for temperature management/comfort. Per licensee there are no firearms stored or present on the premises. Per staff, the most recent fire department inspection was during 2019. There is a working smoke detector, working carbon monoxide detector and fully charged fire extinguisher. The outdoor patio and covered sand box area are fully fenced and available to children in care with adult supervision present. There are no swings or high climbing equipment present. The separate outdoor storage area is off limits to children in care. There are no pools, hot tubs or other accessible bodies of water. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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 Continued on Page 2*************************************************************************************

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019

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: CHOZOM, DOLMA	FACILITY NUMBER: 073406463
	VISIT DATE: 11/05/2019

NARRATIVE

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All required postings are present including parents' rights, facility license and personal rights.
LPA reviewed the facility, staff and children's records including parents' rights forms, emergency ID forms and immunization records. Licensee has current CPR/First Aid which expires There is an up to date roster present.

The Safe Sleep Awareness Campaign PIN packet was provided and discussed. Licensee is encouraged to visit www.ccld.ca.gov for licensing regulations and forms. To sign up for quarterly updates contact: childcareadvocatesprogram@dss.ca.gov.

LPA and licensee reviewed the current Facility Personnel Report Summary and verified that all adults requiring background clearances are cleared and associated to this facility. Licensee will submit livescan fingerprints for a family member who will be staying at this residence for an extended period.

There were no deficiencies cited during this inspection. A notice of site visit was printed and posted and is to remain posted for thirty days. A copy of this report is to be available in the facility records for a period of three years.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019

LIC809 (FAS) - (06/04)

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