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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543908752
Report Date: 09/05/2019
Date Signed: 09/05/2019 12:37:43 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:HERNANDEZ, GLORIA FAMILY CHILD CAREFACILITY NUMBER:
543908752
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 7DATE:
09/05/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gloria Hernandez, LicenseeTIME COMPLETED:
12:45 PM
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(1) LPA Pete Espinoza conducted an unannounced annual/random Inspection. LPA met with Gloria Hernandez, Licensee (Spanish Speaking), who provided a tour of the home, inside and outside, as shown on the facility sketch. There are no firearms in this facility. Swimming pool is fenced per regulation. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. There is no fireplace. The fire extinguishers and smoke detectors meet State Fire Marshall standards. The home is kept clean and orderly, with heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment are observed. There is a working telephone. Adequate supervision is being provided during this visit. Back yard is off-limits to children. Outdoor play areas in front yard are fenced or supervised by the licensee or care giver. Children’s records contain all emergency information specified by regulation. There are no excluded individuals present at this home. All adults who reside or work in the home have a criminal record clearance or exemption as indicated on LIS 555 – Facility Roster. The licensee and other personnel as specified have completed training on preventative health practices including pediatric CPR and first aid; Expires: 02/23/2021.
Licensee provided proof of required immunization (Pertussis/Measles/Influenza) and written declaration declining flu shot AND Certificate of Completion dated: 03/01/2018 for required Mandated Reporter Training.
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
Business hours are Mon-Fri 7:00 AM to 5:00 PM.
NO DEFICIENCIES OBSERVED IN THE AREAS INSPECTED DURING TODAY’S VISIT.
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter EspinozaTELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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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