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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623696
Report Date: 09/16/2020
Date Signed: 09/16/2020 08:02:11 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:STEVENSON, MONICA & ORLANDOFACILITY NUMBER:
343623696
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
09/16/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Monica StevensonTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Kelly met with the applicants at 4:00pm for a pre-licensing via FaceTime /Tele-inspection due to COVID-19 Emergency. Both applicants were present.

Home is one story, 3 bedrooms and 2 bath house. Off-limit areas: All 3 bedrooms, master bath and garage. Applicants rent the home and provided proof of rental agreement. LPA explained about obtaining $300,000 liability insurance. Applicants understand that until a policy is obtained, they must use the affidavit. A copy of the form was provided.
Applicant completed CPR/First Aid and Mandated Reporter Certificates and other paperwork. LPA discussed SIDS reducing the risk with the applicant, including safe sleeping practices. Adult residents have criminal record clearances. Applicant understand of the applicable Civil Penalty per person for those adults including your own child who have not received fingerprint clearances, are not associated to the license and provide care and supervision to the day care children, or live in the home. LPA has provided the applicants with the web site to enable access to all updated forms, requirements and changes.
LPA advised the Applicants of their responsibility to stay current in the requirements of the Department.The web site is (www.ccld.ca.gov).

The fireplace is blocked to prevent access to children. Applicant stated there are no firearms in the home. There is a fully charged Fire extinguisher (2A10BC), smoke detector and carbon monoxide detector. Cleaning compounds are inaccessible to children. Poisons are locked. Sharp utensils are out of children's reach. Medications are stored out of children reach. The backyard is fenced and there are no bodies of water.

You have received a 90 day provisional license as a Family Child Care Home provider, effective date: 9/16/20 The license was issued pending completion of the Preventive Health & Safety training.

Applicants were provided with a provisional license to serve up to either 8 children, two (2) of which must be at least 6 years of age and no more than two (2) may be infants;
or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of 2 years.

This report was provided to licensees via email
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Socorro KellyTELEPHONE: (916)216-7792
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020
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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