073409568-6-25-2024-02-CC-MMAR-D6KTB6-20240625143437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409568
Report Date: 06/25/2024
Date Signed: 06/25/2024 02:34:48 PM

Document Has Been Signed on 06/25/2024 02:34 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:	CAMACHO, GENESIS		FACILITY NUMBER:	073409568
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	06/25/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Genesis Camacho		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/25/2024 Licensing Program Analyst (LPA) Kareeca Sykes and Licensing Program Manager (LPM) Monica Mathur conducted an announced Pre-licensing Inspection at Genesis Camacho's home and met with Applicant, Genesis who has applied for a Change of Location with a capacity of eight (8). Days and hours of operation will be Monday – Friday from 8 am - 4:30 pm. Persons living in the home are Genesis, Her partner and step-daughter aged 10. All adults have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant completed 8-hour Preventative Health & Safety, Nutrition & Lead Poisoning training, 8-hour Pediatric CPR & First Aid (exp Jan 2025), Mandated Reporter training (exp Dec 2024), has documentation for Measles, Pertussis, Influenza opt- out statement for the current flu season. INDOOR: Home is constructed on two levels. LPA inspected the indoor space of the home. It is sanitary and orderly, with heating and ventilation for safety and comfort. There are stairs in the home. The fireplace is located in the Off - Limits Living Room and is screened/barricaded. LPA observed fully charged 3A40BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible. Door access to off limit areas is gated. LPA reminded that smoking, baby walkers, bouncers, johnny jumpers, saucer chairs and similar items are not allowed in family childcare homes. Applicant states there are no pets. ON LIMIT AREAS: First Level: Bedroom 3(Activity/ Nap), Bedroom 4(Activity), Bathroom. Children will be entering daycare through right side yard gate past the backyard through the sliding door into bedroom 4. Continued on Page 2

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CAMACHO, GENESIS	FACILITY NUMBER: 073409568
	VISIT DATE: 06/25/2024

NARRATIVE

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OFF LIMIT AREAS:
First Level: Entrance (Front Door), Kitchen, Laundry Area, Living Room, Dining Area, Closet in Living Room, attached Garage and closet in bedroom 4.
Second Level: Completely off limits (2 bedrooms, 1 bathroom, attic)
Isolation Area: Bedroom 4

OUTDOOR: LPA toured the outdoor areas. The yard is fenced on all sides. No bodies of water were observed. Storage sheds are locked. Observed two large toy chests without locks.
ON LIMIT AREAS: Main backyard
OFF LIMIT AREAS: Two storage sheds

Because the Applicant rents/leases the home, proof of landlord notification is required. LPA observed the Property Owner/Landlord Notification form (LIC9151) that the Applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

LPA discussed and reminded Applicant daycare 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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) or (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.
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SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CAMACHO, GENESIS	FACILITY NUMBER: 073409568
	VISIT DATE: 06/25/2024

NARRATIVE

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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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

On this date, 06/14/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Website links for provider resources:
Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.
Guardian Background Check: www.guardian.dss.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.
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SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CAMACHO, GENESIS	FACILITY NUMBER: 073409568
	VISIT DATE: 06/25/2024

NARRATIVE

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Applicant, was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California

The following items to be completed prior to issue of license:
By 07/02/2024 submit proof of locks on two outdoor toy chests.

Subject to final approval by CCLD Management, the family home is recommended for Small Family Childcare Home license. Exit interview conducted and report was reviewed with the Applicant Genesis Camacho.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

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