<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409081
Report Date: 06/10/2021
Date Signed: 06/11/2021 09:05:01 AM

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:MORENO, ANAFACILITY NUMBER:
073409081
ADMINISTRATOR:MARINAKIS, AMYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 756-2287
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:14CENSUS: 0DATE:
06/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ANA MORENO TIME COMPLETED:
01:00 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
10:00AM: Licensing Program Analyst Alexander met today with Ana Moreno for an ANNOUNCED PRE-LICENSING INSPECTION. Applicant, her husband Arturo Bracamonte and their 3 minor children were present for the inspection. The home is a two story house consisting of 5 bedrooms, 3 bathrooms, living room, family room, eat-in kitchen, laundry room and garage. The family room, kitchen, down stairs bathroom and backyard will be used as the primary areas for day-care. The off limit areas will be the entire upstairs which consists of 4 bedrooms and 2 bathrooms; the living room, the 5 bedroom located downstairs, the laundry room, and the garage. These areas will be inaccessible to children in care by closed and/or locked doors, visual supervision and a safety gate at the bottom of the stairs. Applicant and her husband own the home; proof was shown. Per applicant there are no firearms/weapons located on the premises. There is a fully charged 2A10BC fire extinguisher. The smoke alarm and carbon monoxide detector were both tested today and is in working condition; recommended periodic servicing. There is a hot tub located in the backyard that has a cover that can withstand the weight of an adult and has locks on all 4 sides. All sharp knives, cleaning solutions and medications are inaccessible to children. Cleaning solutions and medications are inaccessible to children. First aid kit is available and complete. The isolation area for sick children will be a secluded area located in the family room. . Outdoor play will be in the backyard which is fully fenced. There are toys and play space available. Due to the structure of the backyard (steep hill & retaining wall) physical supervision is recommended while children are at play to prevent them from climbing the hill/stairs and fence. Applicant was instructed to conduct and document periodic fire and disaster drills. Applicant was informed that baby walkers, exersaucers and baby bouncers are not allowed. Applicant has completed CPR and first aid training which expires in 7/2022 respectively. Applicant has completed her 16 hours of health and safety training which included the 1 hour of Nutrition and 1 hour of Lead poisoning training.

Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies given to applicant. Applicant was instructed on the law establishing a $100 fine per day for adults who are living in the home or who are providing care who do not have fingerprint clearances. Applicant was also instructed on the law requiring notification to parents regarding exclusions.
All forms can be downloaded at www.ccld.ca.gov. www.myccl.gov for day-care updates.
CONTINUED ON 809-C
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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: MORENO, ANA
FACILITY NUMBER: 073409081
VISIT DATE: 06/10/2021
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
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

DURING TODAY'S PRE-LICENSING INSPECTION THE RESOURCE MATERIALS FOR COVID-19 WERE ALSO DISCUSSED TO HELP THE FACILITY STAY SAFE DURING THIS PANDEMIC. THE COVID-19 SELF-ASSESSMENT GUIDE HAS ALSO BEEN GIVEN. REQUESTED COMPLETION AND SUBMISSION.

As a result of today's visit, the following needs to be completed before a license can be granted.



1. THE THORNED ROSE BUSHES LOCATED IN THE BACKYARD ALONG THE FENCE NEED TO BE INACCESSIBLE TO CHILDREN IN CARE TO PREVENT HARM (EITHER FENCE THE BUSHES OR REMOVE THEM) .
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2