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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621695
Report Date: 10/04/2019
Date Signed: 10/04/2019 10:17:53 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:CRUZ, CARMENFACILITY NUMBER:
393621695
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
10/04/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Carmen Cruz TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Carmen Cruz for the purpose of an Increase of Capacity comprehensive inspection. Facility hours of operation are Monday- Saturday 5:00 AM to 10:00 PM. LPA and Licensee toured the home and backyard. Licensee’s husband and mother were present during the inspection. Off-limit areas include: all bedrooms and garage. Licensee acknowledged that children may not enter these off-limit areas. LPA observed care and supervision of two children. Licensee has requested a capacity increase to 14 children. On 09/23/19, Fire clearance has been granted by Stockton Fire and Prevention. Licensee stated there are no new residents in the home since licensure. All adult residents have criminal record clearances.

LPA observed cleaning supplies properly stored out of reach of children. Medications are inaccessible to children and stored on the top shelf of a locked cabinet in the kitchen. The fireplace in the living room is properly screened. Fire extinguisher, smoke detector and carbon monoxide meet regulations. Toys appear to be clean and safe. The backyard is fenced and there are no bodies of water. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify Community Care Licensing of the proposed changes.
In the areas that were evaluated, no deficiencies were observed at the time of the inspection. Capacity increase is approved.

Effective today's date, 10/04/19, LPA will approve the capacity increase to serve up to either 14 children, two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.

Exit interview conducted. Notice of site visit posted.

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

DATE: 10/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2019
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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