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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623873
Report Date: 03/18/2021
Date Signed: 03/22/2021 10:01:55 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:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/18/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Melina JimenezTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Kelly met with the applicants on 3/18/21 at 4:00pm for a change of location inspection via Zoom/Tele-inspection due to COVID-19 Emergency.

Home is a 2 level, 2 bedrooms and 1 bath house (applicant lives on the top level of house, the stairs connecting the top level to the backyard is barricaded, the bottom level is use as storage).

Off limit areas: Master bedroom.

Applicant has current CPR/First Aid certificates, Mandated Reporter Cert. Posted Parent's Rights and current disaster plan. There is a working telephone in the home. 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 and the ADA, available at: http://www.ada.gov/childqanda.htm

Fire Clearance for the home, was granted on 3/12/21 by Fire Marshal

LPA observed knives and other hazardous items properly stored out of child reach. Medicines are stored out of reach of children. There were no hazardous items located in the bathroom. Licensee stated there are no firearms in the home. Fire extinguisher, smoke and carbon monoxide detectors meet Tile 22 Regulations.
There is a wall fire alarm in the home. Toys appear to be safe. The large backyard is fenced and there are no bodies of water on the property.

Effective today: 3/18/21, LPA will approve 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, then it will fall back to the small capacity.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Socorro KellyTELEPHONE: (916)216-7792
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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