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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423712
Report Date: 08/08/2022
Date Signed: 08/08/2022 04:40:27 PM

Document Has Been Signed on 08/08/2022 04:40 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:MOLINA, MITZYFACILITY NUMBER:
013423712
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 0DATE:
08/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Mitzy MolinaTIME COMPLETED:
04:40 PM
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On 8/8/22 at 2:25 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an announced Pre-licensing Inspection at Mitzy Molina home and met with Applicant, Mitzy who has applied for a Small Family Child Care Home with a capacity of 8 children. The home was toured to conduct a Health and Safety Inspection. Present during today’s inspection is applicant and applicant's representative. The Child Care home plans to operate Monday-Friday 8AM-5:30 PM. Living in the home is applicant and applicant's spouse.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

INDOOR SPACE: LPA toured the indoor space of the home. The home consists of living room, laundry room, back yard, 4 bedrooms and 2 bathrooms. IN-USE AREAS: Living room, bathroom 1, bedroom 1, bedroom 2 and backyard. OFF-LIMIT AREAS: Bedroom 3, bedroom 4, laundry room, bathroom 2 and kitchen.

OUTDOOR SPACE: LPA toured the outdoor area (backyard) and it was fully fenced. LPA observed gates blocking the off-limit areas in back yard. LPA did no observed any bodies of water.

LPA observed: fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detector in daycare rooms. Medicines, cleaning products, sharp objects are stored inaccessible to children in off-limit areas. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant states that there are 2 dogs in the home. There are no arms and ammunition stored in the home.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MOLINA, MITZY
FACILITY NUMBER: 013423712
VISIT DATE: 08/08/2022
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LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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 PIN 22-02-CCP. 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

Exit interview conducted and report was reviewed with the applicant Mitzy Molina. Applicant is approved for a Small Family Childcare home License.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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