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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415523
Report Date: 12/22/2020
Date Signed: 12/22/2020 12:39:48 PM

Document Has Been Signed on 12/22/2020 12:39 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CONTRERAS, COLUMBAFACILITY NUMBER:
274415523
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/22/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Columba ContrerasTIME COMPLETED:
12:45 PM
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On 12/22/2020 at 12:00 PM, Licensing Program Analyst (LPA), Susy Cervantes, met with licensee, Columba Contreras, to conducted a case management increase of capacity visit. Adults currently living in the home are licensee and three relatives with two children ages 6 and 8. The days and hours of operation will be Monday through Friday from 5:00 am to 6:00 pm.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/22/2020 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. LPA reminded Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

The home was inspected inside and outside.The home has a working duo smoke and carbon monoxide detector, a working telephone and a fully charge 3A40BC fire extinguisher. Certifications for CPR and First Aid are up-to-date which expire 02/01/22. Fire clearance was granted on 11/22/2020. Mandated Reporter training for Child Care Workers was completed on 02/26/2020. Licensee stated that there is one dog and is vaccinated. Licensee stated there are no firearms/weapons in the home. Off limit areas inside: garage and entire second with four bedrooms, bathroom, master bedroom, master bathroom, and living room. LPA observed barricaded stairs, no wall heaters, and no bodies of water. The backyard is fenced. Off limits outside: left side yard. Medication, cleaning products, hazardous and sharp objects were inaccessible to children and are stored in a locked closet and a top kitchen cabinet.

Continues on report dated 12/22/2020
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2020
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CONTRERAS, COLUMBA
FACILITY NUMBER: 274415523
VISIT DATE: 12/22/2020
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Continuation of report dated 12/22/2020

LPA reviewed with licensee the ratio and capacity for a large FCCH. LPA went over substitute options. Licensee stated that she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the immediate civil penalties for Zero Tolerance of $500 and the Healthy Beverage Act and AB633 requirements for type A violation. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA discussed the “Lead Poisoning Facts Information Flyer” and the Guide to Safe Sleep information with the licensee. Department website: http://ccld.ca.gov provided to Licensee.

Licensee was informed that failure to correct deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA conducted an exit interview with the licensee in Spanish. LPA informed Licensee that the report will be emailed. Licensee understands that in lieu of a signature, a read receipt or confirmation of receiving the report email must be submitted within 24 hours.
LPA advised applicant that Licensure for a large family child care home is granted pending the following:

- Management's approval.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
LIC809 (FAS) - (06/04)
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