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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005507
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:04:06 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:CANALES, EVELYN A.FACILITY NUMBER:
214005507
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
09/15/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Licensee, Evelyn CanalesTIME COMPLETED:
02:15 PM
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On 9/15/2021 at 12:31P.M., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Evelyn Canales. The purpose of the inspection was explained and was a Case Management inspection for increase in capacity. Present was the licensee caring for three children. All children present are preschool age. All adults have their criminal record clearances on file. Per Licensee, no off-limit areas will not be added to the physical plant. Days and hours of operation are Monday – Friday, 8:00 A.M. to 5:00 P.M. Day-care Area: (Lower Level) Living Room (Playroom), Dining Room, Bathroom #1 and Patio. Off-limit Area: (Upper Level): Bedroom #1, Bedroom #2, Bedroom #3 and Bathroom #2. Home was inspected with the licensee for health and safety hazards.

LPA observed the following: Day-care was clean, orderly with plenty of age appropriate toys and games for the children. Cubbies and child size tables and chairs were available. All off-limit area is properly barricaded with children safety gates. Bathroom #1 was clean with adequate supplies. Home does not have a swimming pool, spa, hot tub, fishpond or any other bodies of water. Day-care has a functioning home phone, smoke /carbon monoxide detector combo, and a fully charged fire extinguisher (2A:10BC), located in the kitchen. First aid kit was fully stocked. Licensee's CRP/ fist aid certification is current, expiring: 1/16/2023.

Capacity Limits of a Large License has been reviewed with the licensee. Licensee was reminded that when operating at a large capacity, there must be a helper present.

(REFER TO 809-C FOR CONT.)

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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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: CANALES, EVELYN A.
FACILITY NUMBER: 214005507
VISIT DATE: 09/15/2021
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Prior to recommendation for a Capacity Increase, licensee must submit the following documents:

-Fire Clearance Approval

-Submit updated Application Form (LIC 279)

-Submit updated Children in the home Form (LIC 279B)

-Submit updated Mandated Reporter Training Certification

-Submit Pre-licensing Readiness Guide (LIC 9217)

-Submit immunization record for all occupants

-Clear all outstanding citations

This report must be available in the facility for public review. Notice of site visit was observed being posted. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2