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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409178
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:11:10 PM

Document Has Been Signed on 07/28/2021 03:11 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:ROJAS, XIOMARAFACILITY NUMBER:
073409178
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/28/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Xiomara RojasTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Caroline Colson met with Xiomara Rojas and her teenage daughter for an announced prelicensing and technical assistance inspection at 1:15 PM. There are no day care children present. The home was toured to conduct a health and safety inspection. All required forms was reviewed and given during the inspection. Mrs. Rojas was informed of the new civil penalty assessments of up to $500 per adult during the initial inspection for not having cleared fingerprints on file (if needed) before contact with the day care children.

The home is a one story home. The home consist of three bedrooms, living room, kitchen with dinning area, one inside bathroom, one outside bathroom, unfenced front yard, fenced back yard and a garage. She will take the children to the neighborhood park for outdoor play. All bedrooms, kitchen with dinning area, unfenced front yard, fenced back yard, outside bathroom and garage are the off limit areas. There is 2A10BC fire extinguisher, working smoke detector and working carbon monoxide detector. She has one screened wall heater located in the living room. Mrs. Rojas states that there are no firearms in the home. She provided a rental agreement for the home. There are toys available for the children. Her CPR and First Aid certificates are current and expire on June 20, 2022. The isolation area will be a in the living room. There are no pets.

The following corrections will need to be completed by August 28, 2021:
1. Applicant needs to update her Emergency Disaster Plan.


Please See LIC 809 C for additional information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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: ROJAS, XIOMARA
FACILITY NUMBER: 073409178
VISIT DATE: 07/28/2021
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REMINDERS/RESOURCES
· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

Individual 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 (US DOJ) 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.

An exit interview was conducted. This report must be available for public review for 3 years.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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