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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409178
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:19:40 PM

Document Has Been Signed on 12/05/2022 04:19 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
BAY AREA-CC OAKLAND, 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: 8CENSUS: 3DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Xiomara RojasTIME COMPLETED:
04:34 PM
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On Monday, December 5, 2022 at 2:20 PM, Licensing Program Analyst (LPA) Caroline Colson met with Xiomara Rojas and her assistant, Andrea Hernandez and Catherine Alejo for an unannounced change of capacity and random annual inspection. There are two preschool children and one infant present. The home was toured to conduct a health and safety inspection. Hours of Operation Monday - Friday from 7:00 AM to 5:30 PM.

Indoor Space: 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. 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. There are toys available for the children. Her CPR and First Aid certificates are current and expire on June 20, 2024. Mandated Reporter Training Certificate is current and expires on September 2, 2024. The isolation area will be in the living room. There are no pets. Fire Clearance was received.

Outdoor Play Space: The neighborhood park will be the outdoor play space.

Off-Limit Areas: All bedrooms, kitchen with dinning area, unfenced front yard, fenced back yard, outside bathroom and garage are the off limit areas.


Please See LIC 809 C for additional information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ROJAS, XIOMARA
FACILITY NUMBER: 073409178
VISIT DATE: 12/05/2022
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CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

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



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

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 ADA, available at: http://www.ada.gov/childquanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Family Child Care Homes

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


Please See LIC 809 C for Additional Information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ROJAS, XIOMARA
FACILITY NUMBER: 073409178
VISIT DATE: 12/05/2022
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Safe Sleep

LPA discussed the safe sleep regulations with Xiomara Rojas and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Xiomara Rojas 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.

Licensee will need to submit required documents for assistant and additional parent forms.

Notice of Site Visit

A notice of site visit was given and must remain posted for 30 days.

Exit Interview

Exit interview conducted and report was reviewed with the licensee, Xiomara Rojas.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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