<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622275
Report Date: 03/09/2022
Date Signed: 03/09/2022 09:22:34 AM


Document Has Been Signed on 03/09/2022 09:22 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:HERNANDEZ, GUADALUPEFACILITY NUMBER:
313622275
ADMINISTRATOR:HERNANDEZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 390-3107
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:14CENSUS: 6DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Guadalupe HernandezTIME COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 9th, 2022, Licensing Program Analyst (LPA) Jeremey McClain met with Licensee Guadalupe Hernandez for an unannounced annual inspection.

LPA observed a census of six children, which included two infants and four preschool age children. Licensee stated there aren’t new residents in the home. All adult residents have criminal record clearances.

LPA toured areas of the home accessible to the children. The off-limit areas of the home were inaccessible and unoccupied.

LPA observed current CPR/First Aid certificate which expires 1/2024. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA observed that licensee has current completion of AB1207 Mandated Reporter training through 9/9/2022. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years.
LPA reviewed children's records for completeness, as well as the client roster. LPA observed records of immunizations for MMR, Pertussis, and influenza.

During the interior and exterior inspection:
LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach.
LPA observed a fireplace that was properly screened, and stairs were properly barricaded.
LPA observed a working telephone in the home.
Licensee stated that there are no weapons in the home.
LPA observed a fire extinguisher which licensee stated she was servicing every year. Carbon monoxide and smoke detectors were tested and observed to be functional. LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months.
Equipment and furnishings in areas where children are active appeared to be safe and in working order.
REPORT CONTINUED ON THE FOLLOWING PAGE.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HERNANDEZ, GUADALUPE
FACILITY NUMBER: 313622275
VISIT DATE: 03/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed safe sleep regulations with Licensee and observed appropriate cribs/play pens with a mattress and a tight fitted sheet. LPA observed a sleep log documenting 15 minute checks for infants in care.

This facility does not currently provide Incidental Medical Services- IMS. 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. 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

This report was reviewed with licensee, and an exit interview was conducted. A Notice of Site Visit was provided and should remain posted for 30 days.



No deficiencies were observed during today’s inspection.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2