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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409257
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:20:28 PM

Document Has Been Signed on 04/20/2022 04:20 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:ARROYO, NICOLEFACILITY NUMBER:
073409257
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nicole ArroyoTIME COMPLETED:
04:30 PM
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On 04/20/2022 at 2PM Licensing Program Analysts (LPAs), Monica Mathur and Christina Watts conducted an announced Pre-licensing Inspection at Nicole Arroyo's home and met with Applicant, Nicole Arroyo who has applied for a Small Family Child Care Home with a capacity of eight (8). Days and hours of operation will be Monday – Friday from 2:30 pm - 6 pm. Applicant plans to care for school age children only. There are 2 adults residing on the property. There are 2 children under age 18 in the home.
Applicant completed 8-hour Preventative Health & Safety training, Nutrition and Lead Poisoning training, 8 hour Pediatric CPR & First Aid, has documentation for Measles, Pertussis, Influenza opt out statement for the current flu season. Applicant and adults living in the home have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant owns the home. LPA reminded that when care for more than six and up to eight is provided, Applicant must notify parents. Applicant will use the Affidavit Regarding Liability Insurance form to inform parents they do not carry a day care insurance. Applicant has a working telephone in the home.
Single story Home comprises of 2 bedrooms, 2 bathrooms, Kitchen, Living/Dining room, Class room, Pantry, attached Garage, Front Yard, Backyard, Right Side Yard
Areas to be used for day care: Front Yard, Living/Dining space, classroom, bathroom in classroom, backyard, right side of yard, Kitchen.
Off-Limit Areas: 2 bedrooms, Master Bathroom, Attached garage, Pantry
Isolation Area: Living room
LPA toured the indoor space of the home. It is sanitary and orderly, with heating and ventilation for safety and comfort. There are no stairs in the home. LPA observed fully charged 2A10BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets with latches and locks. LPA reminded that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant states there no arms and ammunition stored in the home.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ARROYO, NICOLE
FACILITY NUMBER: 073409257
VISIT DATE: 04/20/2022
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Outdoor Space: LPA toured the outdoor areas. Children will be using backyard and the right side of backyard. Backyard has hillside that is fenced on top. There are steps leading towards the higher level fence however steps are cordoned off by a child gate. The yard has fences on all sides. No bodies of water were observed. LPA observed a Rock Climbing Structure on the ground that is yet to be installed. Applicant states they plan to install in a few days on the far side of the yard. Applicant will contact Licensing Dept once it is installed.

Discipline policy was discussed, and Applicant states she will talk to the children as form of discipline. She understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented. Applicant plans to transport children from the elementary school.
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.
LPA discussed and reminded Applicant day care needs to be operated within the limitations and capacity of a Small Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours.
This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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
LPA discussed the safe sleep regulations with Applicant, 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 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.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ARROYO, NICOLE
FACILITY NUMBER: 073409257
VISIT DATE: 04/20/2022
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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, 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.

Website links for provider resources:


Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.

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 platform.
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.

The following items to be completed prior to licensure:
1. Climbing Structure installation
2. Pantry door Latch
3. Required postings need to be posted
4. IMS Plan

Applicant will contact Licensing Dept. once these plan of corrections are completed. A follow up Prelicensing Inspection will be conducted before recommended for license.
Exit interview conducted and report was reviewed with the Applicant, Nicole Arroyo.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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