414002998-7-10-2020-05-CC-LGOZ-BRDUSN-20200710155037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002998
Report Date: 07/10/2020
Date Signed: 07/10/2020 03:50:47 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: 6	DATE:	07/10/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee, Evelyn P. Jimenez		TIME COMPLETED:	02:45 PM

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THE FOLLOWING INSPECTION WAS CONDUCTED VIA TELE- INSPECTION DUE TO THE COVID-19 SHELTER-IN-PLACE ORDER.

On 7/10/2020 at 2:00P.M., Licensing Program Analyst (LPA), Luis J. Gomez met with licensee, Evelyn P. Jimenez. The purpose of the inspection was explained and is for a Case Management inspection for an Increase in Capacity. Present is the licensee and helper caring for six children; three preschool age, one school age and two infant age. Licensee is within the required capacity limits of the license on this day. All adults in the home have proper criminal record clearances on file. Day-care Areas are: Living Room (Entry Room), Bedroom #1, Bedroom #2, Bedroom #3, Dining Room (Playroom), Bathroom #1, Bathroom #2, Outdoor play area and Kitchen Off-limit Areas are: Garage, Basement, Side yard, Office (Pass through only) and Laundry Space. LPA inspected home with licensee for health and safety hazards.

At 2:05P.M., LPA observed the following: Day-care area is clean, orderly with age appropriate toys, book and puzzles for the children. All furniture and children's cubbies inspected are in good repair. There are child size tables and chairs available in the kitchen. The off-limit areas are properly barricaded with child safety gates and locked doors. Licensee has infant cribs and child cots stored in the bedrooms. The converted dining room and bedrooms (1# , #2 and #3), located in the primary hallway, are free of hazards or dangerous conditions. Bathroom #1 is maintained clean with adequate supplies for the children. Accessible cabinets have child safe locks installed. Lower cabinets in the facility kitchen have been made inaccessible. Toxins, detergents and cleaning supplies are stored in an off-limit area.

Continuation on 809-C

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JIMENEZ, EVELYN P.	FACILITY NUMBER: 414002998
	VISIT DATE: 07/10/2020

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At 2:20P.M., LPA observed the outdoor play area in completely enclosed. Licensee has installed child gates to separate the on and off limit areas. Licensee has a variety of door playthings that are in good repair. LPA observed the outdoor play area is completely covered for extra shading. Home does not have a swimming pool, spa, hot tub, fishpond or any other bodies of water. The outlets and trash cans in the facility are properly covered. Home has a functioning phone, smoke detector, carbon monoxide detector and a fully charged fire extinguisher (2A:10BC). Licensee has installed a pull fire alarm in the facility.

Licensee was reminded that when operating at a large capacity, there must be a helper present. Capacity limit resource was provided to the licensee.

On 6/19/2020, Fire Clearance Request was granted.

On 7/10/2020, licensee will be recommendation for a Large Capacity

This report must be available in the facility for public review. Notice of site visit was observed being posted. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC809 (FAS) - (06/04)

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