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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623034
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:32:44 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:VALENZUELA, TRACINAFACILITY NUMBER:
343623034
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
05/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Tracina ValenzuelaTIME COMPLETED:
03:11 PM
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On 5/14/2021 at 2:34 PM Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted a tele-inspection via FaceTime with Licensee, Tracina Valenzuela in lieu of conducting an on site inspection due to the COVID-19 pandemic. The current census in the facility during today's inspection was four children. The purpose of today's visit was for an increase in capacity. Licensee has requested a capacity increase from eight to 14 children. A fire clearance has been approved by the local Consumes Community Services District's fire inspector on 5/12/2021.

LPA Birk-Miller observed a working 3-A-40-BC fire extinguisher and a working smoke and carbon monoxide detector. LPA observed the newly installed fire pull system. Licensee stated there are no new residents in the home since being licensed and all adults who require fingerprint clearances have received the required clearance. A healthy and safety inspection was done of the inside and outside of the home. There are are weapons in the home and are locked/stored according to Title 22 regulation. The off limits areas include: master bedroom and bathroom, laundry room, and garage. The licensee understand that if an off limits area is to become on limits or vice versa she will need to contact her LPA. The Licensee's EMSA approved pediatric CPR and first aid certification is current and expires on 8/24/2021. The Licensee's mandated reporter training certificate is current and expires on 5/28/2022. During the inspection Safe Sleep regulations and COVID-19 reminders were discussed.

Effective today 5/14/2021, LPA is granting a license to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years. When there is no assistant present, the facility will revert back to the small capacity.

An exit interview was conducted. LPA send the report via emailed and asked that Licensee send it back once it has been signed.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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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