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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406608
Report Date: 03/04/2020
Date Signed: 03/04/2020 10:19:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CHAGOLLA, ELBAFACILITY NUMBER:
434406608
ADMINISTRATOR:CHAGOLLA, ELBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 942-8782
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:14CENSUS: 7DATE:
03/04/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:ELBA CHAGOLLATIME COMPLETED:
10:30 AM
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On 03/04/2020, Licensing Program Analyst (LPA) Manel Estoesta, met with licensee ELBA CHAGOLLA for an UNANNOUNCED REQUIRED 1 YEAR INSPECTION. Present for this visit were fingerprinted and criminal record cleared ASSISTANT GISELA MARTINEZ GUZMAN, LICENSEE'S MOTHER MARIA DE BECERRA AND 6 PRESCHOOL CHILDREN AND 1 INFANT. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from Monday to Friday 07:00 AM to 06:00 PM.

The home is a one story home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the day care playroom, hallway bathroom, dining room, family room and backyard. The BACKYARD play area is completely fenced. The OFF-LIMIT AREAS are two bedrooms,, master bedroom, master bath, kitchen and the Garage which will be inaccessible by closed and or locked doors and or a fence with visual supervision. The ISOLATION AREA will be the family room. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 01/29/2020. Licensee owns the house and has child care liability insurance with DC Insurance Services Inc.

See LIC 809-C for continuation

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAGOLLA, ELBA
FACILITY NUMBER: 434406608
VISIT DATE: 03/04/2020
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The licensee's CPR and First Aid certificate and expires date 03/31/2020. The licensee completed the mandated reporter training on date 11/09/2019. Licensee's have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. The assistant Gisela's CPR and First Aid certificate and expires date 08/03/2021. The assistant Gisela's completed the mandated reporter training on date 03/03/2018. Assistant Gisela have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.

Facility roster of children was reviewed, and a copy was obtained. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization. The licensee is in ratio today.

Licensee stated that she does transport children at this time, and she has a current and valid Driver License. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

LPA Estoesta discussed and provided copies of of New Safe Sleep Brochure, Lead Poisoning Facts Flyer and California Child Safety Seat Law tothe licensee.



Individual Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

See LIC 809-C for continuation
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHAGOLLA, ELBA
FACILITY NUMBER: 434406608
VISIT DATE: 03/04/2020
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Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. Licensee is encouraged to visit the Department’s website to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, all forms can be downloaded, etc., at https://cdss.ca.gov/inforesources/child-care-licensing


For licensing updates, advised Licensee to email childcareadvocatesprogram@dss.ca.gov and request to be added to the email list. There are no deficiencies cited. This report shall remain on file for 3 years. A copy of the appeal rights was provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
LIC809 (FAS) - (06/04)
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