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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073423678
Report Date: 04/11/2022
Date Signed: 04/11/2022 12:06:24 PM


Document Has Been Signed on 04/11/2022 12:06 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:TSAGARIS, PAULINAFACILITY NUMBER:
073423678
ADMINISTRATOR:TSAGARIS, PAULINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 930-0207
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:14CENSUS: 0DATE:
04/11/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Paulina Tsagaris TIME COMPLETED:
12:10 PM
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On 4/11/22 at 9:45 AM Licensing Program Analyst (LPA) Michelle Sutton conducted an announced Pre-licensing Inspection at Paulina Tsagaris home and met with Applicant, Paulina who has applied for a Large Family Child Care Home with a capacity of 14 children. The home was toured to conduct a Health and Safety Inspection. Present during today’s inspection is applicant, applicant's spouse and daughter. The Child Care home plans to operate Monday-Friday from 7am-5:30pm. Living in the home is applicant, applicant's spouse and 3 children ages 11-14.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

INDOOR SPACE: LPA toured the indoor space of the home. The home is 3-story consists of 2 living rooms, dinning room, kitchen, kitchenette, main room, laundry room, garage, 5 bedrooms and 4 bathrooms.

IN-USE AREAS: Bottom floor of the house: main room, kitchenette, 1 bedroom, 1 bathroom and back yard (play area). LPA discussed to have full supervision when children walk through the living room to the bottom floor (daycare area).

OFF-LIMIT AREAS: Mid-level of the house: 2 living rooms, dinning room, kitchen, office, bedroom, laundry room, garage, horse stable and outside deck.

Top Floor: 3 bedrooms and 2 bathrooms

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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: TSAGARIS, PAULINA
FACILITY NUMBER: 073423678
VISIT DATE: 04/11/2022
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OUTDOOR SPACE: LPA toured the outdoor area (backyard). LPA observed a shed and discussed there needs to be lock for the shed to be inaccessible to children. There are no water body in back yard. LPA observed the back yard is fully fenced. All off-limit areas in the yard are gated.

LPA observed: fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector. Fire clearance was granted for a Large Family child care home. Medicines, cleaning products, sharp objects are stored inaccessible to children in off-limit areas. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare home. Applicant states that there is 1 dog. Ammunition and firearms are locked and stored separately in master bedroom.



Applicant completed the 16-hour Preventative Health training which includes EMSA approved CPR and first aid, one hour of Child Care Nutrition and Lead Poisoning. Applicant has documentation maintained for Measles, Pertussis Immunizations, current opted out statement for the current flu season and Tuberculosis (TB) clearance. Applicant has Criminal Record statement and Child abuse Index Clearance. Applicant owns home and has submitted a copy of the title to CCLD. LPA reminded Applicant that when care for more than twelve and up to 14 is provided, Applicant must notify parents. Applicant will use the Affidavit Regarding Liability Insurance form to inform parents that applicant does not carry a day care insurance. Applicant has a working telephone in the home.

Discipline policy was discussed, and Applicant stated the facility will be separating the child away from the conflict until calming down, will talk to the child and allow the child to come back when they are ready. Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children in bedroom, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire and earthquake drills must be practiced once every six months and documented.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: TSAGARIS, PAULINA
FACILITY NUMBER: 073423678
VISIT DATE: 04/11/2022
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LPA discussed the safe sleep regulations with applicant 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 applicant 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

The following improvements to be completed prior to license of a Large Family childcare home.

  1. Lock on shed
  2. Required Postings
  3. Gates on stairs

Exit interview conducted and report was reviewed with the applicant, Paulina Tsagaris.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

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.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3