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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313633
Report Date: 08/09/2019
Date Signed: 08/09/2019 10:08:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ALGAMA, DONAFACILITY NUMBER:
304313633
ADMINISTRATOR:ALGAMA, DONAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 573-1080
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:14CENSUS: 0DATE:
08/09/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Don AlgamaTIME COMPLETED:
10:20 AM
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A follow up Pre-licensing inspection was conducted by Licensing Program Analyst (LPA) Hawkins. LPA met with the applicant Don Algama. There are three additional adults living in the home. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. A tour of the home was conducted. This pre-licensing inspection is in response to a change of location application submitted by the licensee.

On 7/26/19 an initial prelicensing inspection was conducted and it was determined that corrections must be made to the facility before a license could be issued. Applicants provided updated pictures of the backyard play areas, Pediatric CPR/First Aid /Nutrition Certificates, control of property documents, and pictures of off limit areas of the home gated making them inaccessible to children. During todays inspection LPA observed backyard area cleared from debris; latches on backyard fence; barriers and fence for off limit areas of the backyard; child safety knobs for the laundry room, and changing table for infants was moved to child care room #2.

The home was in compliance with Title 22 Regulations during today's inspection.

LPA informed applicant that a final review of the file, will be done before the license is issued.

Report was reviewed and discussed. Exit interview conducted with applicant Don Algama and signed.The applicant was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
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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