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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620693
Report Date: 11/21/2019
Date Signed: 11/21/2019 01:10:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:COSTA, CRISTINAFACILITY NUMBER:
313620693
ADMINISTRATOR:COSTA, CRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 488-6233
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:14CENSUS: 5DATE:
11/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cristina CostaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Amanda Blesi and Leah Habtom met with the Licensee, Cristina Costa for the purpose of an unannounced Annual inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was 2 infants and 3 preschool age children.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the Master bedroom/bathroom, son's bedroom, backyard and garage. Licensee acknowledged that children may never enter these off-limit areas. LPA observed a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors.

Licensee stated there are no weapons in the home. Toxic and hazardous items (detergents, cleaning compounds, medications, sharp utensils, items that could pose a danger to children in care) are properly stored and inaccessible to children. The wood stove in the home is appropriately barricaded to prevent access by children. There are no stairs in the home. Safe toys and play equipment are observed. The outdoor play space is fenced. There are no bodies of water observed.

Some children’s files were reviewed. A current roster is being maintained. Licensee fire and disaster drills are conducted and documented. CPR and first aid training were verified to be current for licensee.

This provider is currently providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: COSTA, CRISTINA
FACILITY NUMBER: 313620693
VISIT DATE: 11/21/2019
NARRATIVE
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The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the Licensee can request to be added to the distribution list to receive Quarterly Updates.

LPA provided and discussed the Lead Testing brochure (AB 2370) and updated Blue Immunization Cards (CDPH 286)



LPA reviewed and discussed this facility evaluation report with the Licensee. LPA provided a Notice of Site Visit and the Licensee acknowledges that this notice should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at http://ccld.ca.gov for child care updates, current forms, legislation and regulation information.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, deficiencies are noted on the following report. See LIC 809-D. Appeal rights provided.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COSTA, CRISTINA
FACILITY NUMBER: 313620693
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2019
Section Cited

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Mandated Reporter Training: Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion. This requirement was not met as evidence based upon observation of file review. Licensee failed to obtain proof of completion of mandated reporter training for herself and assistant Katy. This poses a potential health risk to children in care.

Type B
12/21/2019
Section Cited

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Employee and Volunteer Immunization
Commencing September 1, 2016, a person shall not be employed or volunteer at a family child care home if he or she has not been immunized against influenza, pertussis, and measles.
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 LPA did not observe Pertussis immunization records for licensee and measles or pertussis for assistant Katy. This could pose a risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3