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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004118
Report Date: 06/05/2019
Date Signed: 06/05/2019 02:18:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MORALES NOVA, GLORIAFACILITY NUMBER:
384004118
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
06/05/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gloria Morales Nova, Lissette RochaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection for a large capacity today. Present at the facility are licensee, Gloria, helper and 5 children. The facility is applying for a large license. LPA explained the requirement for a large license. LPA reminded Gloria that helper must have fingerprint clearance, required immunization on file and AB1207 certificate. LPA advised helper to have current CPR & 1st aid on file. LPA and Gloria toured the home. It is 4 bedrooms, 2.5 bathrooms, living room, kitchen, dining room, 2 car garage, and backyard. Current residents are Gloria, her husband, their 2 children ages 8 months, 4 yr old. Daycare area: living room, dining room, kitchen, bedroom #2, and bathroom next to the kitchen, downstairs room, and backyard. The remaining areas of the house are off limit. The home is equipped with a smoke detector, carbon monoxide detector, and fire extinguisher. Licensee has current CPR and 1st aid certificate on file.

Prior to licensure for large, the following information is needed.

1) fire clearance approval. Fire Marshall verbally approved it.
2) areas under the stairs in the backyard needs to be inaccessible.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019
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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