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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415859
Report Date: 05/08/2019
Date Signed: 05/08/2019 10:34:08 AM

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:CHAVEZ-ROCHA, BIANCAFACILITY NUMBER:
274415859
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
05/08/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Bianca Chavez-RochaTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) met with Bianca today for pre-licensing inspection. Current residents in this home are the applicant, her husband, her 2 minor children, her adult brother and mother. She also has renters, one family live in a trailer on the property and one family live in the 2 bedroom attachment to the main house. Renters include 3 adults and 5 children. All adults living in the home including the renters obtained criminal record and TB test clearance on file. Binaca understand that each time the current tenant moves out and new tenants moves in they have to be finger printed. The home is owned by the applicant's husband; LPA reviewed control of property. The off limit areas inside the home include 3 bedrooms, master bathroom, garage, laundry room and the renters sections, The off limit areas outside all area beyond the 3 feet fence, the trailer, the storage shed. Prior to utilizing any off limit areas, LPA shall provide approval.
The home is heated, ventilated properly. The home is equipped with a fully charged, right size fire extinguisher, a working smoke and carbon monoxide. There is land line phone. The home meets the required posting area. All toxins are inaccessible to children. The home is free of hazardous materials. Applicant states there are no weapons in the home. The play area has 3 feet fence. CPR and First Aid expire on 05/08/20. Applicant has completed the 8 hours Preventive Health and Safety Training. Applicant has all her required immunization records. She completed the Mandated Child Abuse Training.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: CHAVEZ-ROCHA, BIANCA
FACILITY NUMBER: 274415859
VISIT DATE: 05/08/2019
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LPAs reminded applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. LPAs reminded applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes.
Applicant will use redirection as forms of discipline. Applicant understands that children's personal rights should not be violated, no corporal punishment is allowed.
Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements to hire assistant/substitute, emergency disaster drills [(Fire evacuation and Earthquake) drills must be conducted and logged at least once every six months], food provided from home shall be labeled, the new car seat law and healthy beverages in child Care (AB 2084) were also discussed. If liability insurance is not maintained at any time, the Affidavit of Liability Insurance form (LIC 282) shall be provided to parents. If providing care for two additional school age children, the form (LIC 9150) shall be provided to parents.
A Family Child Care Home packet was provided to and reviewed with the applicant. LPA also reminded applicant of the applicable $100 civil penalty per person per day, a maximum of $500 per person for those adults who have not received fingerprint clearances, are not associated to the license who come in contact with or provide care and supervision to the children. LPA discussed the requirements of AB 633 with the applicant and provided her a copy of acknowledgement of receipt of licensing reports (LIC 9224).

Incidental Medical Services (IMS) policy was discussed. She submitted Plan of Operation during visit,
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CHAVEZ-ROCHA, BIANCA
FACILITY NUMBER: 274415859
VISIT DATE: 05/08/2019
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Prior to licensure applicant must:
1) finish tiles on the hallway and the lower part of the wall
2)install a shower curton around the bath tub
3) Clear all the hazardous material in the front yard
4) have TB clearance for her brother.
5)Submit the name of all children living on the property

The above must be corrected no later than 05/22/19.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC809 (FAS) - (06/04)
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