015700460-7-28-2023-52-CC-MPRE-CU6SHB-20230728135314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700460
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:53:25 PM

Document Has Been Signed on 07/28/2023 01:53 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:	TREVISAN, PATRICIA		FACILITY NUMBER:	015700460
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	07/28/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Patricia Trevisan		TIME COMPLETED:	01:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/28/2023 at 11:35am Licensing Program Analyst (LPA) Morgan Pringle met with Applicant Patricia Trevisan for an Announced Pre-Licensing Visit. Present during the inspection was the Applicant and her eleven (11) month old son. Applicant lives in the home with her husband Murilo Trevisan and their infant son. The Applicant’s home was toured for a health and safety inspection. The facility plans to operate 8:00am – 5:30pm, Monday – Friday. ON LIMITS AREA: Living Room, Bathroom, Bedroom between Bathroom and last Bedroom and Backyard OFF LIMITS AREA: Master Bedroom and Bathroom, Bedroom across from Kitchen and Garage ISOLATION AREA: Living Room The facility is a single-story home rented by the Applicant. The home consists of three (3) bedrooms, two (2) bathrooms, kitchen, living room, dining area, backyard, and garage. There is an in-law unit attached to the main home that has its own private entrance and has no access to the main home. The in-law unit is a one (1) bedroom, one (1) bathroom unit. There is one tenant living in the unit. The inside of the home is observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All off limit areas in the home will be made inaccessible with closed doors and locks. The home has centralized heat and air for proper ventilation. LPA did not observe any harmful bodies of water in or around the home. All napping equipment was observed to be clean, free of defects and in good condition. Applicant will be providing all food for the children and will not transport children. There is a 2A10BC fire extinguisher in the bedroom closet. There is a working smoke detector in all three (3) bedrooms. There is a working smoke/carbon monoxide detector in the living room above the television. There are no firearms and no pets in the home.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: TREVISAN, PATRICIA	FACILITY NUMBER: 015700460
	VISIT DATE: 07/28/2023

NARRATIVE

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The Applicant’s Health and Safety training with the lead poisoning component has been completed and Pediatric CPR and First Aid certificates are current and expires 6/24/2025. Mandated Reporter trainings are complete and expires 6/1/2025. All adults living in the main home have obtained a criminal record clearance. The tenant living in the in-law unit has not obtained a criminal record clearance. LPA informed Applicant that since both units are under the same address, the tenant would need to obtain a clearance before licensure. Applicant has provided immunizations for influenza, measles, pertussis and has a current record of tuberculous.

Applicant was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the Applicant that all forms can be downloaded at www.ccld.ca.gov. Applicant was also reminded that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/.

Applicant was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Applicant was reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: TREVISAN, PATRICIA	FACILITY NUMBER: 015700460
	VISIT DATE: 07/28/2023

NARRATIVE

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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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

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 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.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 4/12/2023 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: TREVISAN, PATRICIA	FACILITY NUMBER: 015700460
	VISIT DATE: 07/28/2023

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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) or (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.

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 platforms. 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.

Due to the tenant of the in-law unit needing to obtain a criminal record clearance, facility license will remain pending until clearance is obtained.

Exit interview conducted and report was reviewed with the applicant, Patricia Trevisan.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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