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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423712
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:25:09 PM

Document Has Been Signed on 05/31/2023 03:25 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: 7CENSUS: 4DATE:
05/31/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mitzy MolinaTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Cherie Acosta and Diana Campos conducted an unannounced Case Management/Increase of Capacity inspection. Licensee has an approved fire clearance dated 5/15/23. Licensee has 3 years of experience as a licensed Family Child Care Home at a previous location. Present during today’s inspection was the licensee, 2 preschool aged children and 2 infants in care.

The home was toured for Health and Safety Inspection. On limits area consist of the living room/main child care room, bedroom #1, bedroom #2, and the bathroom located across from the laundry room. The remainder of the home is off limits to children in care. Off limits areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. The home was observed to be orderly, with heating and ventilation for safety and comfort. There are no pools, spas, hot tubs, or any other similar bodies of water at this home. There are no firearms on the premises as stated by the licensee. Detergents, cleaning compounds, medications and other items which could pose a danger to children are stored and inaccessible to children. LPA verified that the fire extinguisher 2A10BC is fully charged. The home is equipped with both a smoke detector and carbon monoxide detector. There is a working telephone in the home. The home provides appropriate toys, learning materials and play equipment. Outdoor play area is fenced.

The licensee is operating within the licensed capacity. LPA did not observe any child left without supervision during the inspection.

Fire and disaster drills are conducted at least once every six months.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MOLINA, MITZY
FACILITY NUMBER: 013423712
VISIT DATE: 05/31/2023
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LPA discussed the safe sleep regulations with licensee 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 licensee of 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.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Licensee has a swing in the outdoor play area that is not anchored to the ground. Prior to approval of the increase in capacity and no later than 6/5/23 the licensee shall either anchor the swing set to the ground or remove it from the play area. Licensee shall ensure children do not play on the swing. Licensee shall submit a self certified letter to CCL ensuring this is done.

A notice of site visit was provided and must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview conducted and report was reviewed with Mitzy Molina.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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