073408132-5-4-2022-02-CC-MGUT-CE4NGK-20220504102715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408132
Report Date: 05/04/2022
Date Signed: 05/04/2022 10:27:58 AM

Document Has Been Signed on 05/04/2022 10:27 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:	POLANCO, PASSION		FACILITY NUMBER:	073408132
ADMINISTRATOR:	POLANCO, PASSION		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 893-8496
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	14	CENSUS: 0	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Passion Polanco		TIME COMPLETED:	10:45 AM

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	On 05/04/22, Licensing Program Analyst (LPA), Melissa Guirit conducted an unannounced Annual Required inspection. LPA met with licensee Passion Polanco. Present for today's inspection was licensee. Per licensee, she has not had any children enrolled for a few months.The home was toured for Health and Safety Inspection. On limits area consist of the living room, dinning room, kitchen, hallway bathroom, first bedroom on the right, and backyard. The off limits areas are all other bedrooms and garage. Off limits areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. There are no firearms on the premises as stated by the licensee. The home has a fireplace that is screened/locked to prevent access by children. LPA verified that the fire extinguisher 2A10BC is fully charged. The home is equipped with both a working smoke detector and carbon monoxide detector. There is a working telephone in the home. Outdoor play area is fully fenced and is free from defects and dangerous conditions. The isolation area for ill children is in the living room. The licensee CPR and First Aid certificate is current and expires 12/7/2023. The licensee's mandated reporter training is complete and she received a certification of completion on 10/7/2021. The licensee is in compliance with the immunization law. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 04/01/22. See 809-C for continuance.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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: POLANCO, PASSION	FACILITY NUMBER: 073408132
	VISIT DATE: 05/04/2022

NARRATIVE

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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.

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.

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

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

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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: POLANCO, PASSION	FACILITY NUMBER: 073408132
	VISIT DATE: 05/04/2022

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

There are no deficiencies cited during today’s inspection.

A notice of site visit was provided and must be posted for 30 days.

Exit interview conducted and report was reviewed with the Passion Polanco.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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