384004125-5-21-2019-05-CC-GSIH-BCDPF6-20190521111613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004125
Report Date: 05/21/2019
Date Signed: 05/21/2019 11:16:17 AM

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:	RIVAS, AGUEDA		FACILITY NUMBER:	384004125
ADMINISTRATOR:	RIVAS, AGUEDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 994-2920
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94124
CAPACITY:	14	CENSUS: 0	DATE:	05/21/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Agueda Rivas & Jessica Armenta		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Singh met with applicant, Agueda Rivas, for a scheduled pre-licensing inspection at the facility. Applicant submitted the application for change of location. Applicant has a family child care home (384001155) at different location. Applicant stated that she bought this house during this month. Applicant provided the proof of ownership during the inspection. This is a two story house. Per applicant, applicant will be living here with her husband, two adult children and one minor child. Hours of operation will be 7:30 AM to 5 PM. LPA Singh inspected the entire home with the applicant for health and safety hazards. Day care areas will be – Family room, Bedroom, Hallway and Bathroom on the ground floor and Backyard. Off limit areas will be – Garage and laundry room on ground floor and entire second floor. Isolation of an ill child will be in the hallway at the house ground floor. The house has proper temperature and ventilation. All the toxins or dangerous materials are stored in off limit areas. There is no fireplace in the house. There are stairs inside the house and in the backyard. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. Applicant has submitted record of all the required immunization, CPR (valid until 03/2021) and Mandated reporter training certificate. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excer saucers are not allowed. Smoking is prohibited in family child care homes. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Safe sleep handout was discussed and provided as a resource. See next page for continuation ................

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RIVAS, AGUEDA	FACILITY NUMBER: 384004125
	VISIT DATE: 05/21/2019

NARRATIVE

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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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The applicant is encouraged to frequently visit out website at www.ccld.ca.gov for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

Prior to issue license, facility needs to complete the following:
· Install the child protective gates at stairs inside the house and outside in the backyard.
· Receive the clearance from the local fire department.

Copy of this report was reviewed and provided to licensee's daughter, Jessica Armenta. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (650) 266-8800.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019

LIC809 (FAS) - (06/04)

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