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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283005594
Report Date: 06/12/2019
Date Signed: 07/01/2019 05:22:38 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ILDEFONSO, ADRIANA FAMILY CHILD CARE HOMEFACILITY NUMBER:
283005594
ADMINISTRATOR:ILDEFONSO, ADRIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 254-0842
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:14CENSUS: 14DATE:
06/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Adriana IldefonsoTIME COMPLETED:
02:00 PM
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The following electronic report was transcribed from the Facility Evaluation report written and completed during an Annual/Random inspection conducted on 6/12/19. Signature of Adriana Ildefonso, authorized facility representative, is on the hard copy LIC 809, and maintained in facility file.

An Annual/Random inspection was made to the facility by Licensing Program Analyst (LPA), Leticia Rosales-Meza. Ms. Ildefonso is a Spanish Speaking. A review of staff records on 6/12/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home. The facility is toured inside and outside. The facility’s operating hours are 6:00 AM - 6:00 PM, Monday - Saturday. The off-limits areas of the home are the two bedrooms, and were made inaccessible by door knob covers and key locked doors. Toxins, sharps and medication were stored out of the reach of children. There is a working smoke detector, carbon monoxide and fire extinguisher in the home. CPR & First Aid expire 5/2021. Licensee states there are no firearms nor poisons in the home. The requirement that poisons are to be locked with a key lock/combination lock is reviewed. The most recent drill was conducted on May 24, 2019. The children use the backyard as the outdoor play area and it is fully fenced. There were no pools or bodies of water observed in the yard.
All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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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