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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409502
Report Date: 03/15/2024
Date Signed: 03/15/2024 11:11:16 AM

Document Has Been Signed on 03/15/2024 11:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:DA COSTA, ADRIANAFACILITY NUMBER:
073409502
ADMINISTRATOR:DA COSTA, ADRIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 326-1780
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
03/15/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:ADRIANA DA COSTATIME COMPLETED:
11:15 AM
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On March 15, 2024, Licensing Program Analyst (LPA) Tasha Alexander met with applicant Adriana Da Costa for the purpose of conducting an ANNOUNCED RE-LOCATION inspection. Ms. Da Costa is the only one living in the home. Present in the home for today’s inspection was the applicant, and 1 infant in care.

The hours of operation will be Monday - Friday, 8:00 AM to 5:00PM, Monday through Thursday and Fridays 8:00 AM to 4:00PM. Age range 6 months old to beginning kindergarten.

The facility is a two story, 5 bedroom, 3 bathroom home rented by the applicant and contains a living room, dining room, family room, kitchen, laundry room, and garage. The home is neat and clean with heating and ventilation for safety and comfort. Per the applicant, the ISOLATION AREA will be in the on-limits family room on a cot away from the other children in care, until the parents pick up.

On-limit-areas include: Living room, dining room, downstairs bathroom, downstairs bedroom which will be used as the infant nap room and the fully fenced backyard. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits areas.

Off-limit-areas include: The entire upstairs, which includes 4 bedrooms and 3 bathrooms, the kitchen, laundry room, garage and the cottage home to the left of the main home, which is fenced off making it inaccessible to children in care. The off-limit areas will be inaccessible by closed and/or locked doors, child gates and/or by adult supervision.

Applicant does not have liability insurance and will have parents sign the notice of no liability insurance and keep the document in the children’s files. Ratios were discussed and a copy left for applicant as a reminder. Per applicant, there are no firearms in the home.

809-C

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DA COSTA, ADRIANA
FACILITY NUMBER: 073409502
VISIT DATE: 03/15/2024
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The home has a working smoke alarm/carbon monoxide detector combo located downstairs near the bathroom. a working telephone, first aid kit, and a fully charged 3A40BC fire extinguisher which meets standards established by the State Fire Marshal.

A copy of the rental agreement was reviewed and shows control of property. The applicant completed and received a certificate in mandated reporter training on 05/24/2024. Licensee's CPR and First Aid certificate is current and expires 11/26/2024. Outdoor play per licensee will be in the fully fenced backyard.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

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.

LPA discussed the safe sleep regulations with applicant, and discussed the Child Care Licensing Safe Sleep webpage 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. Today there are 4 play yards available for napping.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DA COSTA, ADRIANA
FACILITY NUMBER: 073409502
VISIT DATE: 03/15/2024
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The 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.

LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The applicant was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

Roster of the children must be properly maintained and fire/disaster drill every six months must be documented. The applicant is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

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. Applicant reminded to have the parent board with required documents at the entry of the home and/or where the parent enter.

Entrance Checklist was provided to the applicant.

Exit interview conducted and report was reviewed with the applicant,Adriana Da Costa. Appeal rights provided. This home is recommended for Licensure on March 15, 2024.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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