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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010118
Report Date: 09/22/2021
Date Signed: 09/22/2021 10:53:22 AM

Document Has Been Signed on 09/22/2021 10:53 AM - 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,
, CA
FACILITY NAME:MARTINEZ, RACHELL FCCHFACILITY NUMBER:
283010118
ADMINISTRATOR:MARTINEZ, RACHELLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 337-7364
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rachell Martinez, LicenseeTIME COMPLETED:
11:05 AM
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A pre licensing inspection was conducted today by Licensing Program Analyst (LPA) Kevin O'Connell. This applicant is relocating their Large FCCH from 283010020 to the above address. Services will be available Monday - Friday, 7:30 AM - 4:00 PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a three bedroom/two bathroom, dual level home. There are two adults living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.
The floor and yard plans are verified. The children will have access to the entire downstairs level minus the garage. The "off limits" areas include the home's entire second floor and the garage. These areas will be made inaccessible by latches, and child gates. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. Applicant stated that there were no firearms and ammunition in the home at the time of this inspection. Applicant states that there are no poisons at this time but will key lock them in the back yard shed if needed. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies are and will be maintained at the facility. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and a fire extinguisher rated at least 2A10BC. The home does not have a fireplace and stairs are barricaded. The home's backyard is fully fenced and will be used for childcare. Half of the yard will be used for care and half is "off limits" divided by a fence. There is no spa, pool, pond, or fountain on the premises.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Kevin O'Connell
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MARTINEZ, RACHELL FCCH
FACILITY NUMBER: 283010118
VISIT DATE: 09/22/2021
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Incidental Medical Service (IMS) regulations were reviewed with the applicant. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department. Applicant does not offer IMS to any children at this time.
Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property or landlord notification/consent is on file. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in any area where child care is provided. The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
Before approval for licensure, the applicant will complete a current Pediatric CPR/First Aid course, provide updated facility sketches for the first and second levels of the home.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Kevin O'Connell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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