214005238-10-14-2019-05-CC-JSAI-BGXTBQ-20191014143531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005238
Report Date: 10/14/2019
Date Signed: 10/14/2019 02:35:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	LOPEZ, LETICIA		FACILITY NUMBER:	214005238
ADMINISTRATOR:	LETICIA LOPEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 893-0269
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	14	CENSUS: 5	DATE:	10/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	LETICIA LOPEZ		TIME COMPLETED:	02:50 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	Licensing Program Analyst (LPAs) Jyoti Saini and Farhan Bashir-Tariq conducted an Annual Inspection, which included a tour of the home and back yard, and a review of the required day-care forms with the licensee today. Present in the home were 5 children with licensee and one helper, Iris Beltran. Facility is operating in ratio on this day. A review of records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Day-care operates M-F, 7:30 AM - 5:00 PM. LPAs observed the following: day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there are no bodies of water on the property. There are no detergents, or cleaning products accessible to day-care children. Poisons are locked. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced off (Licensee must be directly present with children any time they are outside). Licensee has a dog present in the home and LPAs observed immunization records of the dog. Licensee’s CPR and First Aid card expires 02-09-21. Emergency drills are conducted at least once every six months and properly logged. Per log, last drill was conducted on 7/16/19. Licensee provides Breakfast, Lunch and two snacks. Discipline policy is redirection. Isolation of sick children was discussed. Children’s roster was reviewed and is complete and up-to-date. Children and staff files were reviewed and are complete. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist). Licensee has updated immunization record and Mandated Reporter Training on file. Continuation on next page...

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LOPEZ, LETICIA	FACILITY NUMBER: 214005238
	VISIT DATE: 10/14/2019

NARRATIVE

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Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website
(www.ccld.ca.gov or www.mandatedreporterca.com). Licensee was advised of the upcoming changes to regulations regarding ‘Safe Sleep” and provided with handouts regarding “safe to sleep “best practices.

No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations.
This report and appeal rights were discussed with Licensee. This report must be available in the facility for public review. Notice of Site Visit was posted. Notice to remain posted for 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

LIC809 (FAS) - (06/04)

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