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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623829
Report Date: 01/21/2021
Date Signed: 01/21/2021 01:05:41 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:JOHNSON, ERIQUETTAFACILITY NUMBER:
343623829
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
01/21/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eriquetta JohnsonTIME COMPLETED:
01:04 PM
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LPA Kelly met with applicant via FaceTime due to COVID-19 emergency for the purpose of conducting a Change Of Location inspection. Applicant is requesting a Change of Location that will include 8 children. LPA toured the home. The backyard is completely fenced and no bodies of water were observed. Home is a 2 story, 4 bedrooms and 3 bath house. Off limit areas: include entire second floor, laundry room and garage. Licensee acknowledged that children may never enter these off-limit areas. LPA observed current Pediatric CPR and First Aid and Mandated Reporter Certs. Adults in the home are fingerprint and child abuse cleared. Posted Disaster Plan, Parents Rights and COVID-19 guidelines. LPA did not observed hazardous items within access to children. There were no hazardous items located in the children's bathroom. All knives were stored out of the reach of children, stairs is barricaded by a gate and fireplace is blocked. Applicant stated there are no firearms in the home.

LPA observed a 2A10BC fully charged fire extinguisher and several smoke and Carbon Monoxide detectors in the home. Applicant does not have the $300,000 liability insurance at this time and plans to use the affidavit in the meantime. Toys appear to be safe. LPA did not observe any bodies of water on the property or other hazardous items in the backyard or front yard. All areas observed in the home during todays inspection are in compliance.

As of today's date: 01/21/21, LPA will grant a license to serve up to either 8 children, two (2) of which must be at least 6 years of age and no more that 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 applicant via email to be signed and returned to LPA.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Socorro KellyTELEPHONE: (916)216-7792
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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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