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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911248
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:07:11 PM

Document Has Been Signed on 05/18/2022 01:07 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:COSTA, CHELSIE FAMILY CHILD CAREFACILITY NUMBER:
543911248
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
05/18/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Chelsie CostaTIME COMPLETED:
01:20 PM
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On May 18, 2022, Licensing Program Analyst (LPA), Norma Lomeli conducted a capacity increase inspection from a Small Family Child Care Home to a Large Family Child Care Home. Present at time of inspection was licensee, licensee's husband, Licensee's Assistant, Jordyn Duran and eight day care children. Licensee, her husband and three minor children reside in the home. Verified licensee’s CPR and First Aid was completed through Pediatric Plus with Emergency Medical Services Authority stickers (EMSA) and expires on November 13, 2023. Licensee’s Assistant, Jordyn Duran who completed the training through Pediatric Plus with Emergency Medical Services Authority stickers (EMSA)and expires on February 25, 2024. Background criminal record clearances are verified and discussed, and LIS 531 is signed indicating that the adults living in the home and/or providing care and supervision to children have a criminal record clearance. Fire clearance was granted on April 27, 2022.

A tour of the four bedrooms and two bathrooms home was conducted inside and outside, as shown on the facility sketch, was conducted and the following was discussed and/or observed:
  • Fire clearance was received on May 10, 2022. Fire alarm is located on the left hand side dining room wall.
  • LPA observed children size furniture, safe toys and books for the children. LPA also observed a high chair. There is a parent’s board that is located on the right hand side of the hallway wall.
  • Licensee states she does not have weapons, firearms, ammunition or poisons in the home.
(Continued on LIC809-C):
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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: COSTA, CHELSIE FAMILY CHILD CARE
FACILITY NUMBER: 543911248
VISIT DATE: 05/18/2022
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Licensee is advised the following items must be corrected and documentation be sent to Fresno CCL within the next 30 days to avoid possible withdraw.
  • Licensee will update the Mandated Reporter Training certification.

Pending verification of correction of the above item and a final review of her application, licensure as a Large Family Day Care Home capacity of 8 children ages under 18 years will be recommended.

During exit interview, LPA observed licensee post the Notice of Site Visit on parent’s board and understands it must remain posted for 30 days and retain evaluation report for 3 years.
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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: COSTA, CHELSIE FAMILY CHILD CARE
FACILITY NUMBER: 543911248
VISIT DATE: 05/18/2022
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  • Facility has 2A10BC fire extinguisher, carbon monoxide alarm, working smoke alarm and first aid kit in place.
  • Licensee is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
  • Licensee is advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Licensee states the home is smoke-free.
  • Licensee states she will be transporting day care children. Licensee understands that she must have proper restraints and/or car seats for all the children under her care when transporting children.
  • Required items are posted in the Child Care Home where parents may easily view.
  • During visit capacity worksheet was provided and discussed.
  • Licensee completed the Mandated Reporter Training on January 6, 2020. Licensee’s Assistant completed the training on November 24, 2021.
  • LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given licensee.


LPA & licensee discussed the Community Care Licensing website: LPA and licensee discussed new additions to the website that include the new PIN (Provider Information Notification) and information for providers including the Quarterly Update that informs licensees of new legislation and regulations. Please follow these steps go to http://www.cdss.ca.gov/, click on “information and resources” click “Community Care Licensing” Click “quarterly updates” click “Child Care advocates program” and register to PIN.

Licensee states her hours of operation are Monday through Friday from 7:30am to 5:00pm and as arranged. Licensee advised she does not provide overnight care, less than 24 hours. Licensee is advised she may access forms and updated information on the CCLD website at www.ccld.ca.gov.
(Continued on LIC809-C):
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Norma Lomeli
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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