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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200011
Report Date: 10/07/2019
Date Signed: 10/07/2019 12:20:31 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:AYALA, ELVIA GFACILITY NUMBER:
214200011
ADMINISTRATOR:AYALA, ELVIA GFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 892-5819
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:14CENSUS: 1DATE:
10/07/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Elvia AyalaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with the Licensee Elvia Ayala for a Plan of Correction inspection on 10/07/19. The purpose of the inspection was explained. Present, there was one child in care with the Licensee. All adults living or working in the home have fingerprints clearance on file. Licensee is operating within the capacity and ratio limits as of today 10/07/19.

This was a follow up visit from the previous inspection of 9/19/19. During the previous inspection, LPA cited Licensee for not having a working carbon monoxide detector and missing immunization records for Licensee. LPA observed that Licensee has installed a working carbon monoxide detector in the home. LPA performed the test to check the detector. LPA observed Licensee's immunization records.


Deficiencies are cleared today and a copy of the POC letter was generated and handed to the Licensee.


SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019
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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