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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:42:48 PM

Document Has Been Signed on 04/27/2022 03:42 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: 12CENSUS: 7DATE:
04/27/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Guadalupe ClarkTIME COMPLETED:
02:30 PM
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On 4/27/22 at 1:45 pm Licensing Program Analysts (LPAs) Monica Mathur and Christina Watts conducted an unannounced Case Management inspection and met with Licensee, Guadalupe Clark (also known as Lupita). Present in the home during inspection were 7 children (5 infants, 2 preschool), Licensee (Guadalupe) and Helper (Teresa Ramirez)

Licensee wants to add the THIRD BEDROOM to the In-Use areas for day care. LPAs inspected the bedroom which is located adjacent to the Laundry Room. Licensee wants to use it as a Nap Room and has 2 cribs set up. LPAs reminded that when she uses cribs for infants under age 2, she has to follow Safe Sleep Regulations which include but not limited to - keep door open, no stuffed animals/objects in cribs, maintain Sleep Log for infants, 15 minute checks.

Third Bedroom is approved for day care use.

Effective today the following are use/off limit areas in the home:
IN USE AREAS: Living room, Family room, Dining area, Kitchen, Child Bedroom, Bathroom in Hallway, Bathroom in Laundry Room, Laundry Room, Third Bedroom
OFF LIMIT: Master Bedroom, Garage converted into Shop

At 2:30 pm exit interview conducted and report was reviewed with the Licensee, Guadalupe Clark and son Patrick Clark. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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