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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700233
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:39:05 PM

Document Has Been Signed on 09/07/2022 03:39 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:MOULAS, MARIETTAFACILITY NUMBER:
015700233
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marietta MoulasTIME COMPLETED:
03:15 PM
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On Sept 6, 2022, Licensing Program Analyst (LPA) Sidney Cortez conducted an inspection with applicant Marietta Moulas and her husband Dean Moulas. The purpose of this inspection was to conduct an Announced Pre Licensing Inspection. Applicants plan to operate the facility Monday through Friday from 8:00am until 5:30pm. Present for this visit is the applicant. The home was toured to conduct a Health and Safety Inspection.The home is 1 story. The home consists of 3 bedrooms, 2 bathroom, living room, dining room, kitchen, backyard and garage

There is no pool or any type of bodies of water in the home. Per applicant, there is no fire-arm in the house. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS is the 2 bedrooms, and the other bathroom (master bedroom). The ON LIMIT AREAS are the 1 bedroom (napping area), living room, dining room, hallway bathroom (hallway), play area in the garage and backyard. The ISOLATION AREA is the living room area.
There are toys and learning materials in the activity room area.Hazardous materials and toxins are kept out of the reach of children and it was observed that there would be no toxins or hazardous items accessible to children during today's inspection.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MOULAS, MARIETTA
FACILITY NUMBER: 015700233
VISIT DATE: 09/07/2022
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The home has one fully charged fire extinguisher (model 2A10BC), and working smoke/carbon monoxide detectors, first aid kit, emergency supplies, and working telephone. The applicant’s Health and Safety training is completed, and licensee’s CPR and First Aid certificates are current and both certificates will expire on March 2023. Licensee has also has a certificate for the Lead Poisoning Training completed in Jan 2021.
The applicant is in compliance with new immunization law. Applicant received a certificate in mandated reporter training on Feb 19, 2021 which is valid for 2 years. A Property Owner/Landlord Notification of the property was given by the applicants.
Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov.

LPA Cortez provided a copy of Safe Sleep-in child care brochure, a handout "What Does A Safe Sleep Environment Look Like," and a copy of the new California Car Seat Law Changes. The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370).

This home is recommended for licensing. This report shall remain on file for 3 years. Exit interview conducted with licensee.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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