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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409342
Report Date: 11/10/2022
Date Signed: 11/10/2022 04:44:13 PM

Document Has Been Signed on 11/10/2022 04:44 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:DA COSTA, ADRIANAFACILITY NUMBER:
073409342
ADMINISTRATOR:DA COSTA, ADRIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(628) 888-4530
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
11/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:ADRIANA DA COSTATIME COMPLETED:
05:00 PM
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Licensing Program Analyst Alexander and Licensing Program Manager Dyson met with Adriana Da Costa for an ANNOUNCED RE-LOCATION INSPECTION. Applicant is the only one present for the inspection. The home is a two story home consisting of 4 bedrooms, 3 bathrooms, living room, family room, eat-in kitchen, and garage. The living room, downstairs hall bathroom, family room and backyard will be used as the primary areas for day care. The off limits areas will be the entire upstairs which includes 4 bedrooms and 2 bathrooms, and garage. These areas will be inaccessible to children in care by closed and/or locked doors and visual supervision and safety gates at the top and bottom of the stairs. Applicant rents the home; proof was shown. Per applicant there are no firearms/weapons located on the premises. There is a 3A40BC fire extinguisher in the home and working smoke alarm/ carbon monoxide detector combo which was tested today and is in working condition; recommended periodic servicing. There are no swimming pools, hot tubs or other bodies of water located on the premises. All sharp knives, cleaning solutions and medications are inaccessible to children in care. First aid kit is available and complete. The isolation area for sick children will be a small area located in the dinning room that is adjacent to the main day care area (living room). Outdoor play will be in the backyard which is fully fenced. There are toys and play space available. Applicant was instructed to conduct and document periodic fire and disaster drills. Applicant was informed that baby walkers, exersaucers and baby bouncers are not allowed. Applicant is scheduled to update her CPR and first aid training on 11/28/2022. Applicant has completed her 16 hours of health and safety training which included the 1 hour of Nutrition and 1 hour of Lead poisoning training.

DURING TODAY'S PRE-LICENSING INSPECTION THE RESOURCE MATERIALS FOR COVID-19 WERE ALSO DISCUSSED TO HELP THE FACILITY STAY SAFE DURING THIS PANDEMIC.

All forms can be downloaded at www.ccld.ca.gov. www.myccl.gov for day-care updates.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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 2
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: DA COSTA, ADRIANA
FACILITY NUMBER: 073409342
VISIT DATE: 11/10/2022
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Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies given to applicant. Applicant was reminded 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.
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 the ADA, available at: http://www.ada.gov/childqanda.htm

THE FOLLOWING NEEDS TO BE COMPLETED BEFORE A LICENSE CAN BE ISSUED:



1. PROOF OF UPDATED CPR & 1ST AID TRAINING.




An exit interview was conducted
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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