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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415883
Report Date: 07/11/2019
Date Signed: 07/17/2019 05:08:17 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:BELMONTES, NIEVESFACILITY NUMBER:
444415883
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
07/11/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 AM
MET WITH:Nieves BelmontesTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Elizabeth Berumen conducted an unannounced case management inspection due to an increase in capacity request. LPA met with Licensee, Nieves Belmontes and explained the nature of today's inspection to her. No day care children were present. Nieves is not providing day care services at this time and is working full time outside of the home. Licensee's daughters were present during the inspection. Licensee, Nieves Belmontes and 2 friends (Maria Santos, and Mayra Ruiz) are the only adults living in the home. Nieves has three daughters ages 13, 8, and 2 years old. Nieves understands that her 8 and 2 year old daughters will count in her capacity when they are present.
A review of staff records on 07/09/19 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 completed her Preventative Health and Safety Child Care Training including one hour of nutrition. Licensee's CPR and First Aid certifications are current and expire 04/2020. 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: are entire upstairs (4 bedrooms, 2 bathrooms) and garage. Stairs are barricaded. Fire place in day care area is barricaded. LPA observed a fully charged 2A10BC fire extinguisher, working smoke detector, and a working carbon monoxide detector. 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 July 3, 2019. Rooms marked on map "prohibida" are not approved for child care use.
A license (capacity 14) is approved today.
NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019
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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