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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500342
Report Date: 11/24/2020
Date Signed: 11/24/2020 12:16:44 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:EVELYN, PATRICIAFACILITY NUMBER:
394500342
ADMINISTRATOR:EVELYN, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 487-2610
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:14CENSUS: 0DATE:
11/24/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Patricia EvelynTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Charlotte Baney conducted pre-licensing - change of location tele-inspection via Facetime with Patricia Evelyn due to COVID-19 pandemic in lieu of an on-site inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted inside and out. The single story home 3 bedrooms, 2 bathrooms, a living room, dining room, kitchen and patio. The off-limits areas in the home are all bedrooms and kitchen. Off-limits areas will remain inaccessible to children in care. There is a metal screen gas fireplace in the home.

Toxic and hazardous items are inaccessible to children. A functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher were observed in the home. Applicant does not have Liability Insurance and will use the lic 282. Applicant stated there are no weapons in the home. LPA observed proof of applicant's immunization in the facility file.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPAs also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov

Report continues on LIC 809-C
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Charlotte BaneyTELEPHONE: (916) 216-7791
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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: EVELYN, PATRICIA
FACILITY NUMBER: 394500342
VISIT DATE: 11/24/2020
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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years. The fire department granted a fire clearance for a capacity of 14 and he also approved the garage to be used as a day care room on 11-23-2020.



As of today 11/24/20, facility is approved for a large license with a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Charlotte BaneyTELEPHONE: (916) 216-7791
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC809 (FAS) - (06/04)
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