434414381-7-9-2021-52-CC-MPRE-C4RMQL-20210709094856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414381
Report Date: 07/09/2021
Date Signed: 07/09/2021 09:49:02 AM

COMPREHENSIVE INSPECTION

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:	MAZA-OCHOA, MICHELLE		FACILITY NUMBER:	434414381
ADMINISTRATOR:	MAZA-OCHOA, MICHELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 391-9663
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	14	CENSUS: 1	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Michelle Maza-Ochoa		TIME COMPLETED:	09:48 AM

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	On 7/09/2021 at 8:45am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Michelle Maza-Ochoa for an unannounced annual inspection. Present during the inspection was the Licensee. Licensee’s live in the home with their fingerprint cleared husband Jorge Delgado. There was one (1) infant preset during the inspection. The Licensee’s home was toured for a health and safety inspection. The operating hours are 7:30am – 5:30pm Monday – Friday. ON LIMITS AREA: Living Room, Dining Room, Bathroom and portion of Backyard OFF LIMITS AREA: Room 1, Room 2, Room 3, Kitchen, Garage, Portion of Backyard, Storage Shed in Backyard ISOLATION AREA: Living Room The facility is a single-story home rented by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and one (1) dog in the home. The home has one (1) fully charged 3A40BC fire extinguisher located in the living room. One (1) working carbon monoxide detector in the dining room and one (1) working smoke detector in the living room and the dining room. LPA observed a wall heater in the dining room that Licensee has blocked off with wood making it inaccessible to the children in care. The home is equipped with many windows for proper ventilation. LPA observed no bodies of water in or around the home. Cont on 809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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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: MAZA-OCHOA, MICHELLE	FACILITY NUMBER: 434414381
	VISIT DATE: 07/09/2021

NARRATIVE

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At 9:15am LPA obtained the facility roster and the children’s files. The files and the facility roster were complete. The Licensee’s Health and Safety training has been completed and CPR and First Aid training is current with an expiration date of 9/14/2021. Licensee’s Mandated Reporter training is current expiring on 1/10/2022. All required forms are posted and visible for public view next to the from door.

Licensee was reminded that California Law requires 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 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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.

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 $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.
Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

This report was read and given to the Licensee for a signature. There are no deficiencies being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given and must be posted for 30 days.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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