393621695-6-18-2021-53-CC-ESIA-C44T78-20210618142819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393621695
Report Date: 06/18/2021
Date Signed: 06/18/2021 02:28:23 PM

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, CARMEN		FACILITY NUMBER:	393621695
ADMINISTRATOR:	CRUZ, CARMEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 561-5120
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	14	CENSUS: 1	DATE:	06/18/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Carmen Cruz		TIME COMPLETED:	02:45 PM

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On Friday 06/18/21 at 01:45 pm Licensing Program Analyst (LPA) Elvira Sierra met with Carmen Cruz, for an unannounced annual inspection. Upon arrival present in the facility was Licensee caring for 1 infant. Licensee's mother was also present. Facility hours of operation are: M-S from 05:30 a.m to 05:30 p.m. Capacity and ratio requirements were met on this day. All adults living and working in the home have criminal record clearances on file with Licensing Office. Licensee stated that no new residents moved into the home since licensure.

At 01:55 p.m. a health and safety inspection was conducted in all areas accessible to children and the following was observed; Off-limits areas are: All bedrooms, bathroom # 2 next to bedroom #3,garage,and locked backyard shed. Licensee understand that children may never enter these off-limits areas. The facility appeared orderly and suitable for children. LPA observed the required postings, a working telephone, 2A10BC fire extinguisher and functioning smoke and carbon monoxide detectors. A variety of toys and learning equipment available to the children. LPA observed weapons and ammunition locked separately in an area inaccessible to children. There are no bodies of water on the premises. Medications, toxic and hazardous items are inaccessible to children. The fireplace in the home is appropriately barricaded. Licensee stated fireplace has never been used and doesn't work. Outdoor play area is fenced for supervision and is free from defects or dangerous conditions.
Children’s files were reviewed and a copy of the emergency information card was observed in each child's record. LPA observed a current children’s roster and proof of Fire and disaster drills that were properly log.

CPR and First Aid certification was verified and expires on 10/23/2022.

Report continues on subsequent page 809C---

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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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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: CRUZ, CARMEN	FACILITY NUMBER: 393621695
	VISIT DATE: 06/18/2021

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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.

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed Safe Sleep regulations.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. This report and Notice of Site was provided. Notice of Site Visit should be remain posted for 30 days.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

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