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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006320
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:52:20 PM


Document Has Been Signed on 04/12/2023 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CARRILLO, ANGELICA FAMILY CHILD CARE HOMEFACILITY NUMBER:
493006320
ADMINISTRATOR:CARRILLO, ANGELICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 838-8554
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:14CENSUS: 7DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Angelica "Angie" CarrilloTIME COMPLETED:
01:13 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. A review of staff records on 04/12/2023 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. There are currently three adults living in the home.

During today’s inspection the home and grounds were toured. The licensee was supervising one child. The facility’s operating hours are 06:30am to 05:30pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The children have access to the home's kitchen,dining room, living room, and hall bathroom. The licensee requested permission to use the home's living room for childcare use. The living room was inspected during this visit and approved for child care use. An updated floor sketch was obtained from the licensee. The off-limits area of the home include all bedrooms and the garage and was made inaccessible by door locks and/or latches. The home was observed to be clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire June 2024. The licensee's CA mandated reporter training certificate expires May 2024. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated that poisons, firearms, and ammunition are are not stored on the premises. The children use the home’s fully fenced back yard as the outdoor play area. There are no bodies of water observed on the premises. Five child's record was reviewed during today's inspection. Children's immunization records, identification and emergency forms, and notification of parent's rights forms were on file. The LPA reviewed infant safe sleep regulations and discussed infant safe sleep plans and safe sleep logs. Continued on LIC 809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CARRILLO, ANGELICA FAMILY CHILD CARE HOME
FACILITY NUMBER: 493006320
VISIT DATE: 04/12/2023
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 (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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Angelica Carrillo. There were no Title 22 deficiencies cited during today's inspection.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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