493006320-10-30-2020-01-CC-YYAG-BUVV9A-20201030161401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493006320
Report Date: 10/30/2020
Date Signed: 10/30/2020 04:14:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	CARRILLO, ANGELICA FAMILY CHILD CARE HOME		FACILITY NUMBER:	493006320
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	10/30/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Angelica Carrillo		TIME COMPLETED:	11:28 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	A tele visit inspection was conducted today by Licensing Program Analyst (LPA) Y. Yang in response to an increase capacity application received 10/20/20. Due to the COVID-19 pandemic, a tele-visit inspection was conducted in place of an in-person, site visit. The licensee is requesting a capacity of 14. The licensee has met the required experience for a large family child care home. The approved fire clearance was received on 10/27/20 for the requested capacity. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently four adults living in the home.The garage and all bedrooms are off limits. The off-limits areas are made inaccessible with child gates and/or latches. The living room, dining room, kitchen, and hall bathroom are on-limits. Licensee stated she understands that off-limits areas will need to be made inaccessible at all times during child care hours. The children will use the home's backyard as the outdoor play area and it is fully fenced. Poisons are locked in a shed in the backyard. Ratios for a large family child care home were reviewed. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a working smoke detector, carbon monoxide detector, and charged fire extinguisher rated 2A:10B:C in the home.The licensee stated there are no firearms and other dangerous weapons are stored on the premises. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CARRILLO, ANGELICA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493006320
	VISIT DATE: 10/30/2020

NARRATIVE

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The licensee is not providing Incidental Medical Services – IMS. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 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,www.ada.gov/childqanda.htm. All licensing reports are public information and must be made available upon request for at least three years.

The increase of capacity application is granted effective 10/30/20.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC809 (FAS) - (06/04)

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