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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010030
Report Date: 04/19/2021
Date Signed: 05/10/2021 01:55:21 PM

Document Has Been Signed on 05/10/2021 01:55 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MILA'S PRESCHOOL AND CHILDCARE CENTER-INFANTFACILITY NUMBER:
173010030
ADMINISTRATOR:KRYSTAL GOMEZFACILITY TYPE:
830
ADDRESS:21036 WASHINGTON STREETTELEPHONE:
(707) 968-5005
CITY:MIDDLETOWNSTATE: CAZIP CODE:
95461
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
04/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mila ZavaletaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Glenn Ouye meet with Mila Zavaleta, Krystal Gomez and Sharlene Gomez to conduct a combination center prelicensing walk through for the purpose of capacity determination.

LPA measured the square footage of the infant interior activity area. LPA produced a capacity determination worksheet. The maximum capacity is limited by the square footage of 300 square feet. This will provide regulated square feet to meet the capacity needs of 8 infants. The facility has changing table and sink within arms reach. There is a separate staff bathroom. The outdoor square footage is 896 sq feet. This will exceed the regulatory requirements for the 8 children. The facility has operational smoke detectors and carbon monoxide detector in the facility. There are fire extinguishers rated at 2A10BC. There is sufficient cribs, cots, furniture and play equipment for the children. The facility sign in and out will be located at the sliding door which tentatively will be the main entrance for the infant room. LPA and the applicant discussed the Covid-19 self assessment mitigation plan. A copy of the plan was completed and provided for the department. PPE, sanitation, check in and out health screening and cohorts were discussed.

The applicant indicated that the fire inspector required a few items to be completed before the fire clearance is approved. The applicant will work with completion of items and will notify the fire inspector for final approval.

LPA Ouye is reviewing the application for all required documents for licensure.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2021
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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