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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623984
Report Date: 08/23/2021
Date Signed: 08/23/2021 09:26:56 AM

Document Has Been Signed on 08/23/2021 09:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:GONZALEZ, MINERVAFACILITY NUMBER:
313623984
ADMINISTRATOR:MENDOZA, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 219-4048
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Minerva GonzalezTIME COMPLETED:
09:15 AM
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On August, 23rd, 2021, Licensing Program Analysts (LPAs) Jeremey McClain wit applicant Minerva Gonazalez for the purpose a change of location pre-licensing inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Operating hours will be from 8:00 am - 4:00 pm.

A health and safety inspection was conducted inside and out of the home. The home appeared orderly and equipped with age appropriate furniture and equipment. The home consists of 4 bedrooms, 2 bathrooms, a living room, kitchen, a laundry area and fenced backyard. The off-limits areas in the home are the master bedroom and bathroom. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Toxic and hazardous items are inaccessible to children. LPA observed functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher. A fire clearance was granted on 08/04/2021. Current pediatric CPR and first aid training was verified and is current. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Applicant stated that there are no weapons in the home. Applicant was encouraged to maintain supervision at all times. Immediate Civil Penalty regulation deficiencies were reviewed.

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.

As of today, the applicant is approved for a Large Family License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Kindergarten or elementary school and 1 child at least age 6 with a maximum of 3 infants.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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