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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409257
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:36:10 PM

Document Has Been Signed on 05/05/2022 03:36 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: 8CENSUS: DATE:
05/05/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nicole ArroyoTIME COMPLETED:
04:15 PM
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On 05/05/2022 at 3:30 PM, Licensing Program Analysts (LPA's) C. Watts and A. Curry conducted an announced follow up pre licensing inspection. LPA's met with applicant Nicole Arroyo to inspect the pantry door and outdoor climbing structure in backyard. Also present for the inspection was applicant's husband, who has fingerprint clearance, as well as applicant's two minor children.

LPA's verified the pantry door is secured with a latch and made inaccessible to children in care. Rock climbing wall was observed to be secure in place and safe for children to use. Applicant climbed the wall to test structure's ability to hold the weight of an adult. Applicant also installed mats below structure to absorb a fall. License will be effective as of today, May 05, 2022.

Exit interview was conducted , appeal rights were given and report was reviewed with applicant, Nicole Arroyo.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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