493009773-6-27-2019-01-CC-ASTR-BDJQRK-20190627122404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 06/27/2019
Date Signed: 06/27/2019 12:24:12 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:	PEREZ, EMILIO FCCH		FACILITY NUMBER:	493009773
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	06/27/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Emilio Perez		TIME COMPLETED:	12:30 PM

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 prelicensing inspection visit was conducted on 06/27/19 by Licensing Program Analyst (LPA), Amy Strother. The applicant is requesting a license for a capacity of 8. Services will be provided Monday - Friday; 6:30 a.m. - 6:30 p.m. The applicant understands that child care must be provided in the "primary" residence of the applicant. The residence is a five bedroom/four bath home. There is one adult living in the home. Applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. The floor and yard plans are verified. The garage and the entire upper floor of the home is off limits to the children. The garage has been made of limits with a door lock and the upper level of the home has been made inaccessible by a child safety gate at the bottom of the staircase. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. The applicant stated that there are no poisons stored on the premises and none were observed during today's inspection. The applicant reports there are no weapons in the home and none were observed during the visit. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector carbon monoxide detector and fire extinguisher rated at least 2A10BC. The home has two fireplaces downstairs, each fireplace is securely screened or barricaded. The children will use the backyard as the outdoor play area. The backyard is completely fenced. There is no trampoline on the premises. There is no pool, spa, pond, fountain, nor any other source of water accessible to the children, and none is to be added without prior notification and approval of the licensing agency. Continued on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019

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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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: PEREZ, EMILIO FCCH	FACILITY NUMBER: 493009773
	VISIT DATE: 06/27/2019

NARRATIVE

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Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property or landlord notification/consent is on file. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current on Pediatric CPR and First Aid. The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current Pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited during the hours of operation in those areas where children are present.

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. This report, the AAP Guide to Safe Sleep Practices brochure, as well as the Community Care Licensing website were reviewed and discussed with the applicant.

The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/ Megan's Law web site was provided
(http://www.meganslaw.ca.gov). The licensee understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

The following needs to be completed prior to the granting of the license. Please include facility number in all correspondence.

1. Proof of posting Parent's rights, Emergency Care and Disaster Plan, and Earthquake Preparedness Checklist.
2. Updated facility sketch showing off-limits areas.
3. Proof of securing 2 bookcases to the wall of the double sided fire place in entry room, one on each side.
4. Signed statement from assistant Maria Medina declining the influenza vaccine.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019

LIC809 (FAS) - (06/04)

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