115405760-9-13-2019-13-CC-LCHZ-BFYQA9-20190913115935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 115405760
Report Date: 09/13/2019
Date Signed: 09/13/2019 11:59:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	ACEVEDO, MARISOL FAMILY CHILD CARE HOME		FACILITY NUMBER:	115405760
ADMINISTRATOR:	ACEVEDO, MARISOL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 988-6261
CITY:	ORLAND	STATE: CA	ZIP CODE:	95963
CAPACITY:	14	CENSUS: 4	DATE:	09/13/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Marisol Acevedo		TIME COMPLETED:	12:05 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	An annual random inspection was made to the facility by Licensing Program Analyst (LPA), Laura Chavez. A review of staff records on 9/12/2019 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There is currently one adult living in the home. During today’s inspection the home and grounds were toured. The licensee was supervising four children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 5:00am to 5:30pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the three bedrooms, and were made inaccessible by locks and doorknob covers. The home is clean, orderly and comfortable. There are safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 3/19/2021. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. The licensee stated that there are no poisons in the home and none were observed. Licensee understands that any poison brought into the home shall be locked as required. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the backyard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Seven children's records were reviewed at 11:15am; required emergency information was observed to be on file. During today's inspection the licensee stated she did not have a current roster of children in care. The licensee is not providing Incidental Medical Services (IMS) to children in care. Report continued: See LIC 809C

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura Chavez	TELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME	FACILITY NUMBER: 115405760
	VISIT DATE: 09/13/2019

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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 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 American Disabilities Act (ADA), www.ada.gov/childqanda.htm. This report, as well as information regarding Safe Sleep Practices were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura Chavez	TELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME	FACILITY NUMBER: 115405760
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/30/2019 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement was not met as evidenced by: the licensee's roster of children in care is incomplete.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura Chavez	TELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019

LIC809 (FAS) - (06/04)

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