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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621278
Report Date: 02/10/2020
Date Signed: 02/10/2020 11:11:45 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:BUSTOS, LORRAINEFACILITY NUMBER:
393621278
ADMINISTRATOR:BUSTOS, LORRAINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 221-6771
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY:14CENSUS: 9DATE:
02/10/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lorraine BustosTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Stacey Williams met with licensee, Lorraine Bustos for an unannounced random annual inspection. There were (9) nine children present during today’s inspection. Licensee’s husband was also in the home during the inspection. Criminal record clearances were verified.

LPA toured areas of the home accessible to children in care. Off-limit area is the laundry room, entire upstairs and the garage. The backyard is fenced, and licensee acknowledges that children may never be left unsupervised in an unfenced area of the front yard. There are no bodies of water observed.

Required licensing postings were viewed on a bulletin board in the entry of the home. Hazardous items and cleaning supplies and medications are inaccessible to children. Fire extinguisher and smoke detector meet regulation. Carbon monoxide detector was operable.

LPA observed fire drills are conducted and documented to meet regulation guidelines. LPA reviewed CPR/First Aid certification which expires in December 2021.

LPA reviewed children and licensee’s file. Immunization records were reviewed. All required licensing forms were verified in each file.


Report continues the following page, LIC 809C
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: BUSTOS, LORRAINE
FACILITY NUMBER: 393621278
VISIT DATE: 02/10/2020
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LPA discussed the Mandated Reporter Training with licensee. Mandated training is to be renewed every two years and available at: HTTP://WWW.MANDATEDREPORTERCA.COM . Mandated reporter certification was verified in licensee’s file.

Incidental Medical Services (IMS) policy was discussed. 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.

There were no Title 22 deficiencies observed during today’s inspection.

This facility evaluation report was reviewed and discussed with the licensee.

Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information.

The implementation of AB 2370, lead exposure in Family Child Care Homes and proposed safe sleep regulations was discussed. A copy of this report will remain on file for a period of 3 years for public review upon request. A notice of site visit was provided and should remain posted for 30 days for parental review. Appeal rights were discussed and provided to licensee.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2020
LIC809 (FAS) - (06/04)
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