343622553-8-13-2021-53-CC-JBIK-C5UPUG-20210813113732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343622553
Report Date: 08/13/2021
Date Signed: 08/13/2021 11:37:38 AM

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:	REVELES-MEDINA, MARIA & ANGELES, JR. JESUS		FACILITY NUMBER:	343622553
ADMINISTRATOR:	REVELES-MEDINA, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 623-5574
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	14	CENSUS: 12	DATE:	08/13/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Jesus Angeles Jr.		TIME COMPLETED:	11:45 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 08/13/2021 at 10:10 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller met with Licensee, Jesus Angeles Jr. for the purpose of an unannounced annual inspection. The census was 12 day care children in care. During the inspection two assistants were present. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety inspection was conducted in all areas accessible to children. The off-limits areas of the home are: all bedrooms and garage. LPA observed the required postings, a working phone, 2-A-10-BC fire extinguisher, and functioning smoke and carbon monoxide detector. Licensee stated there are no weapons in the home. There are no bodies of water. Toxic and hazardous items are inaccessible to children. LPA reviewed seven children's files and observed that each child has their emergency contact information. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. The Licensee's Pediatric CPR and First Aid expires 03/2022. The Licensee's Mandated Reporter certificate is current and expires 03/2023. The website for the Mandated Reporter Training is mandatedreporterca.com . This provider is currently not 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. 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. Report continues on 809-C.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun Birk	TELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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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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: REVELES-MEDINA, MARIA & ANGELES, JR. JESUS	FACILITY NUMBER: 343622553
	VISIT DATE: 08/13/2021

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LPA verified the annual fees are current. This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

At this time no deficiencies were cited. An exit interview was conducted. Notice of Site Visit was given and posted.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun Birk	TELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC809 (FAS) - (06/04)

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