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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403680
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:58:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ROSALES, CARMENFACILITY NUMBER:
434403680
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
12/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Carmen RosalesTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Deanna Villagrana conducted an unannounced case management inspection due to an increase in capacity request. LPA met with Licensee, Carmen Rosales and explained the nature of today's inspection to her. Present were licensee, licensee's mother and two day care children. Licensee, licensee's husband and adult son live in the home. Licensee's mother is visiting from Mexico.

A review of staff records on 12/07/2021 indicates that facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Days and hours of operation will be Monday - Friday from 6:00 AM to 6:00 PM. Licensee's CPR and First Aid certifications are current and expire 08/07/2023. Licensee completed Mandated Reporter training on 02/08/2020. Applicant owns the home, LPA reviewed proof of ownership.

LPA inspected the indoor and outdoor areas during today's visit. Off limit areas inside the home: master bedroom/bath, two bedrooms, one bathroom and hallway closet. In the day care area there are two closets that will be off limits and one bedroom. LPA did not observe stairs or a fireplace in the home. LPA observed a fully charged 2A10BC fire extinguisher, working smoke detector, and a working carbon monoxide detector. Off limits area outside the home are: right side that is fenced off to children and locked storage LPA observed a fenced side yard and no bodies of water. Licensee states that there are no weapons in the home. Cleaning Products, toxic agents, medications, and sharp objects were stored inaccessible to children.
Fire Approval was granted on 11/23/2021. Rooms marked on map that are crossed out are not approved for child care use.
A license (capacity 14) is approved pending managers approval.
NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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