073406575-10-16-2019-02-CC-PPEN-BGZR2V-20191016123900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073406575
Report Date: 10/16/2019
Date Signed: 10/16/2019 12:39:07 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:	COSTA, MARIA		FACILITY NUMBER:	073406575
ADMINISTRATOR:	COSTA, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 524-3329
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY:	14	CENSUS: 5	DATE:	10/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Maria Costa		TIME COMPLETED:	12:40 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 inspection for this facility at 1110. LPA met with licensee, Maria Costa, and toured the on limits areas of the facility. Also present were five children in care consisting of three infants and two preschoolers. Licensee's 15 year old son also arrived while LPA was present. The facility is within ratio and capacity. The on limits areas for children in care are the main day care room, the dining room and living room area, and the hall bathroom. All on limits areas were inspected for a health and safety inspection. Electrical outlets are safety capped. Cabinets and drawers have child safety fasteners and there were no observed hazardous items/toxins accessible to children in care. Furnishings and equipment, including infant sleeping equipment, are age appropriate and free of observed sharp/broken pieces. Per licensee there are no firearms stored or present on the premises. LPA reviewed the current Facility Personnel Report Summary with licensee and verified that all adults age 18 or older who require background clearances are cleared and associated to this facility. The facility has a working smoke detector, working carbon monoxide detector and fully charged fire extinguisher. There is heating and ventilation available for temperature management/safety. The disaster drill log is current. The outdoor patio/play area is fully fenced and available to children in care. There are no high climbing pieces of equipment or swings. There are no pools, hot tubs or other accessible bodies of water. 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: 10/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019

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 2

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: COSTA, MARIA	FACILITY NUMBER: 073406575
	VISIT DATE: 10/16/2019

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
26
27
28
29
30
31
32

Page 2***************************************************************************************************

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

LPA reviewed the facility, staff and children's records including parents' rights forms, emergency ID forms and consent for emergency medical treatment forms. Licensee has current CPR/First Aid certification which expires 06/2020. The facility roster is current.

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.

There were no deficiencies cited during this inspection. A notice of site visit was printed and is to remain posted for thirty days. A copy of this report was provided to licensee and is to be maintained 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: 10/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2