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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 05/25/2017
Date Signed: 04/15/2022 03:30:26 PM

Document Has Been Signed on 04/15/2022 03:30 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:CLARK, GUADALUPE & JUDSONFACILITY NUMBER:
070209044
ADMINISTRATOR:CLARK, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 937-6152
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
05/25/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Guadalupe ClarkTIME COMPLETED:
03:45 PM
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3 LPA, Hollie, met with the Licensee for the purpose of a Random Health and Safety Inspection. Present in care today are six day care children. Also present is the Licensee and her assistant, Teresa Ramirez. The entire home remains ON LIMITS to day care children. A tour of the home was conducted. The OFF LIMITS remain the outside upper portion of the backyard. The licensee understands that the OFF LIMITS portion of the yard must remain inaccessible to children at all times. There are no bodies of water or fire arms on the premises, per the licensee. The Licensee is present in the home and ensures that children are supervised. There are no children in locked cars.

The home is orderly with heating and ventilation for safety and comfort. Poisons, detergents, cleaning compounds, medications and other items which could pose a danger to children are inaccessible during this visit. Fireplaces and open face heaters are screened to prevent access by children. There is a charged 2a10bc fire extinguisher and a working smoke detector as well as a carbon monoxide detector in the home. There are no stairs in the home. The home has toys, play equipment and materials for children. The licensee is aware that when she is temporarily absent from the home, she must ensure that a fingerprint cleared adult is present with current CPR/First Aid. The facility is operating within her licensed capacity today. SEE 809-C FOR CONTINUED REPORT

SUPERVISORS NAME: Zakiya Ali
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2017
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: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 05/25/2017
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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. The licensee is not caring for children who require Incidental Medical Services.

THERE ARE NO DEFICIENCIES CITED DURING THIS VISIT.

SUPERVISORS NAME: Zakiya Ali
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2017
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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: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 05/25/2017
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There are comfortable accommodations, furnishings and equipment for children. There is a current roster and LPA viewed the roster during the visit. The licensee and her assistant has current CPR/First Aid which expires in 10-18. The licensee understands that all person’s 18 years of age or older, who frequently visits, works or resides in the home, shall be fingerprint cleared/associated to the home, PRIOR to being in the presence of children. LPA reviewed a sampling of children’s records for documentation of Immunization and Notification of Parents Rights. The home conducts and documents fire drills as required.

LPA provided Licensee with a printed copy of the A Child Care Provider’s Guide to Safe Sleep material.

LPA DISCUSSED WITH LICENSEE THAT AS OF SEPTEMBER 1, 2016, ANY PERSON(S) EMPLOYED OR VOLUNTEERING AT A FAMILY DAY CARE HOME SHALL BE IMMUNIZED AGAINST INFLUENZA, PERTUSSIS AND MEASLES OR MUST QUALIFY FOR AN EXEMPTION. LPA INFORMED THE LICENSEE IF PERSON’S DO NOT WISH TO OBTAIN AN INFLUENZA VACCINE, A WRITTEN STATEMENT DECLINING THE FLU SHOT MUST BE AVAILABLE DURING THE VISIT.

LPA encouraged the Licensee to review our website at the above address at CCL.CA.GOV to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business.


THE LICENSEE WAS PROVIDED A COPY OF THEIR APPEAL RIGHTS (LIC 9058 12/15) AND THEIR SIGNATURE ON THIS FORM ACKNOWLEDGES RECEIPT OF THESE RIGHTS. LPA POSTED THE REQUIRED POSTINGS FOR PUBLIC VIEWING.

SEE 809-C FOR CONTINUED REPORT

SUPERVISORS NAME: Zakiya Ali
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2017
LIC809 (FAS) - (06/04)
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