073408132-4-4-2024-02-CC-THAR-D3ZRDF-20240404125551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408132
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:56:19 PM

Document Has Been Signed on 04/04/2024 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
OAKLAND CC RO, 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:	04/04/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	PASSION POLANCO		TIME COMPLETED:	12:45 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	On 4/4/2024 at 9:30am Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Passion Polanco for an ANNUAL/RANDOM INSPECTION. Present during the inspection was the Licensee and her two minor children. Licensee’s home was toured for a health and safety inspection. The facility operates from 2:40pm – 5:30pm, Monday - Friday. ON LIMITS AREA: Living room, Dining room, kitchen, hallway bathroom, and backyard. OFF LIMITS AREA: All 3 bedrooms are now off limits and garage ISOLATION AREA: Living Room The facility is a single-story home rented by the Licensee and her husband Michael Estrada. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee stated that she provides all snacks for the children. Licensee operates an after school program, she states that she transports to and from school. Licensee has a Class C license. There are multiple pets in the home, 2 dogs and 2 cats. Per licensee, there are no firearms in the home. There is one (1) fully charged 2A10BC fire extinguisher in the kitchen. There is one carbon monoxide detector in the childcare in the hallway. The fireplace in the living room is locked making it inaccessible to the children in care. Licensee uses tables and chairs for eating. Licensee operates an after school program, children do not nap at the facility. The home has central heat and air. Licensee also utilizes ceiling fans for ventilation. Continued on 809-C

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 725-2831
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: POLANCO, PASSION	FACILITY NUMBER: 073408132
	VISIT DATE: 04/04/2024

NARRATIVE

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The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. LPA did not observe any harmful bodies of water in or around the home.

Licensee is not open for day care today. Licensee’s Health and Safety training with Lead Poisoning component has been completed and Pediatric CPR and First Aid training is complete and expires 1/2026. Licensee’s Mandated Reporter training is complete and expires 1/5/2026. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 3/19/2024. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted in the childcare room by the entrance door. LPA obtained the children’s files and facility roster. All files were complete.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com

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.

Continue on 809-C

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 725-2831
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: POLANCO, PASSION	FACILITY NUMBER: 073408132
	VISIT DATE: 04/04/2024

NARRATIVE

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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. LICENSEE DOES NOT CARE FOR INFANTS

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.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 725-2831
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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