073408651-9-2-2021-02-CC-LCHW-C6GUAR-20210902152510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408651
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:25:15 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:	MATTOS, ANGEL M		FACILITY NUMBER:	073408651
ADMINISTRATOR:	MATTOS, ANGEL M		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 586-6834
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	14	CENSUS: 7	DATE:	09/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	MATTOS, ANGEL M		TIME COMPLETED:	03:24 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 9/2/2021 Licensing Program Analyst (LPA) L. Chew conducted an unannounced Annual Random Inspection. LPA met with licensee Mattos, Angel. LPA explained the purpose todays inspection. LPA was guided on tour of facility inside and out. The home is a single story 3-bedroom 2-bathroom with attached 2-car garage. Home consist of living room, dining room, kitchen,and fully fenced backyard. The home has heating and ventilation for safety and comfort. LPA observed living room has a barricaded/screened fireplace. The on-limits area consists of living room, dining room, hallway bathroom, kitchen and two (2) bedrooms located to the right, at the end of hallway.The off-limit areas consist of Master bedroom/Master bathroom, garage, and left and right side of the backyard which will be inaccessible by securely closed gates. The isolation area will be the living room. The outdoor play area is free from defects or dangerous conditions. Outdoor play area has a trampoline and chicken coop which is inaccessible to children in care, separated by secured gate. Present during inspection were Licensee, fingerprint cleared/associated Assistant Vivian Sisk, Licensee school age child (14 y/o) and 7 children in care (2 infants and 5 preschoolers). Licensee stated two adults (Licensee & fingerprint/associated husband) and 1 school-age child reside in home. LPA observed the licensee is operating within the license capacity. Licensing states operation hours 07:00AM to 5:30PM Monday thru Friday. Licensee states ages served is infants to school-age. LPA did not observe any bodies of water on the premises, during inspection. LPA did not observe any hazardous materials and/or toxins during inspection. Licensee has 12 pets (2 dogs, 1 cat and 9 chickens).Mandatory forms were posted in prominent, publicly accessible areas of home for public view. Licensee has a current roster of the children in care available for review and copy was obtained. Home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) -69-0243
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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: MATTOS, ANGEL M	FACILITY NUMBER: 073408651
	VISIT DATE: 09/02/2021

NARRATIVE

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Licensee and Assistant is following the new immunization law which pertains to day care providers. Licensee Preventative Health and Safety training was completed 02/25/2018. Licensee Pediatric CPR and First Aid certificate is current, expiring 10/26/2021. Licensee AB-1207 Mandated Reporter Certificate is current, expiring 12/03/2022. Licensee Assistant Pediatric CPR and First Aid certificate is current, (expire 06/21/2023) and AB-1207 Mandated Reporter Certificate is current, (expire on 06/05/2023). Facility Disaster Fire drill was completed on 06/07/2021. Licensee has proof of Control of property was provided by Deed of Trust, Trustor Ronnie Mattos and Angel Mattos, husband and wife.

Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children or an immediate civil penalty can be assessed. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home. The total licensed capacity for a Large Family Child Care Home shall not exceed fourteen children.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates. Safe Sleep regulations was discussed. 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)-514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
California Law Requires Family Child Care Home Licensees to Report Unusual Incident or injuries to children in care to the child's parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624B). Do not leave an Unusual Incident Report on the Licensing Program Analyst voice mail.

There are no deficiencies cited during today’s inspection. Exit interview was conducted with Licensee. A copy of the appeal rights, Notice of Site visit provided. The Notice of Site visit must remain posted for 30 days.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) -69-0243
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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