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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115407899
Report Date: 05/11/2022
Date Signed: 05/11/2022 09:06:39 AM


Document Has Been Signed on 05/11/2022 09:06 AM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:CHAVEZ, PAULINA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115407899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Paulina ChavezTIME COMPLETED:
09:06 AM
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Licensing Program Analyst, Mendez conducted a case management facility inspection on 5/11/22 at 8:40am. This inspection was in response to an application for increased capacity that was received by the Department.The licensee has requested a capacity increase to 14 children.

The LPA toured the facility's indoor and outdoor areas. The off-limits areas of the home are the three bedrooms and made inaccessible by door knob covers. The LPA reviewed the ratio's for a large license and the licensee acknowledged she understood the ratio requirements. The LPA also reviewed the Safe Sleep requirements with provider. Provider has a full time assistant and has required forms for assistant.



Licensee's CPR/First Aid was completed and expires on 3/2023. Based on the space/accommodations available at this facility and the fire marshal granting their approval on 4/14/22 for the 14 children, the capacity increase request is granted. LPA will process this capacity increase and mail an updated license to reflect this capacity change to 14 children. An exit interview was conducted with licensee.

Notice of Site Visit was given to licensee to post for 30 days.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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