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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500308169
Report Date: 11/14/2019
Date Signed: 11/14/2019 01:12:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CAPDEVIELLE, LINDAFACILITY NUMBER:
500308169
ADMINISTRATOR:CAPDEVIELLE, LINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 527-7058
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:14CENSUS: 3DATE:
11/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Linda CapdevielleTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Angelica Mejia and Norma Lomeli conducted an unannounced annual/random inspection and met with Licensee Linda Capdevielle. LPAs explained the reason for the inspection, conducted a tour of the home both inside and outside, and a census was taken.

The rooms accessible to children in care are: master bedroom, bedroom #1 and #2, bathroom, living room, family room, kitchen, and dining room. Off-limits rooms are made inaccessible via plastic door knob spinners and locks. Licensee stated that she does not use her backyard while children are present. Children are supervised when outside in the unfenced front yard. Licensee stated she has two dogs; Licensee understands the liability and safety of children around pets and accepts responsibility. There are no "bodies of water" on the premises. There are no firearms or ammunition in the home. Poisons are locked in accordance with Title 22 regulations. Cleaning compounds, medications and other hazardous items are inaccessible to children. Fireplace is screened and inaccessible to children in care. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment were observed.

There is a working telephone and the number was verified. Adequate supervision is being provided during this inspection. Capacity as specified on the license is being maintained. Licensee has a current roster of the children and maintains emergency information and forms as required. A review of records indicates that immunization records are on file for children and adults. Licensee has provided parents with a copy of the Family Child Care Home Notification of Parent's Rights (LIC 995A). Fire/disaster drills are conducted every six months and documented; the last drill was conducted on 08/27/2019. Licensee is aware that children are never to be left in parked vehicles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present in the home. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care.

(Continued on LIC809-C)

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Angelica MejiaTELEPHONE: (559) 341-6126
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: CAPDEVIELLE, LINDA
FACILITY NUMBER: 500308169
VISIT DATE: 11/14/2019
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Pediatric CPR/First Aid is current and expires 10/24/2020. Mandated Reporter training AB 1207 for Licensee is current and expires 04/05/2020. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. Postings such as Emergency Disaster Plan, Earthquake Preparedness checklist, facility license and notification of parent’s rights poster are posted in the kitchen. Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address. Days and hours of operation are Monday – Friday, 07:30 AM – 05:00 PM, and as arranged.

This facility does not provide Incidental Medical Services (IMS). Licensee is aware that an IMS plan is required to be submitted to Community Care Licensing (CCL) if any of these services are provided. LPA discussed IMS with Licensee and left the Plan for Providing Incidental Medical Services (IMS) – FCCH Requirements. 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



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov, Provider Information Notices (PINS), Quarterly Updates, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, and Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited.

An exit interview was conducted with Licensee and a copy of this report was provided and discussed.
THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
LIC9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Angelica MejiaTELEPHONE: (559) 341-6126
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2