414002998-7-2-2019-05-CC-GSIH-BDQ2RV-20190702173809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002998
Report Date: 07/02/2019
Date Signed: 07/02/2019 05:38:15 PM

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:	JIMENEZ, EVELYN P.		FACILITY NUMBER:	414002998
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 7	DATE:	07/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Evelyn P. Jimenez		TIME COMPLETED:	04:30 PM

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 Analysts (LPAs) Singh and Medrano met with licensee, Evelyn Jimenez, for an annual random inspection. The purpose of the inspection was explained. Licensee lives in a single family home. Present, there are seven children in care. All adults living or working in the home have criminal background check on file. Licensee is operating within the capacity of this date. Licensee provides day care from Monday to Friday between 7 AM to 6 PM. LPAs inspected the day care areas with the licensee. Day Care Areas: Living Room, Bedroom # 1, Bedroom 2, Bedroom # 3, Bathroom in hallway, Dining Room, Kitchen and Backyard. Off limit areas: Garage. There is no pools, spas or other bodies of water on the property. As per licensee, there is no firearm or weapon in the house. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. There is no fireplace and stairs in the house. The house is in good repair and free of hazards with proper temperature and ventilation. The house has a smoke and carbon monoxide detector in the living room. House has fully charged fire extinguisher and working telephone available in the house. There is a variety of age appropriate toys in the house. At 3:00 PM, LPAs review the children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has record of training of preventive health and CPR card valid until November 2019. Licensee has record of children’s immunization. Record of licensee’s immunization was checked previously. Licensee has children’s roster on file. LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Licensee has completed the training. Per completion certificate, training was completed on March 21, 2018. 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: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

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: JIMENEZ, EVELYN P.	FACILITY NUMBER: 414002998
	VISIT DATE: 07/02/2019

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LPA encourage the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

No deficiencies are cited today. The copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019

LIC809 (FAS) - (06/04)

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