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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623142
Report Date: 06/18/2021
Date Signed: 06/18/2021 11:25:07 AM

Document Has Been Signed on 06/18/2021 11:25 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:VALLEJO, MARICRUZFACILITY NUMBER:
343623142
ADMINISTRATOR:VALLEJO, MARICRUZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 718-5246
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maricruz ValeejoTIME COMPLETED:
11:30 AM
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On Friday, June 18, 2021, LPA Pitts met with licensee Maricruz Vallejo for the purpose of a required 1 year annual inspection. Annual fees are up to date. Upon arrival, LPA observed 9 children being supervised by Licensee and Licensee's assistant. All individuals subject to criminal background review have obtained a criminal record clearance. LPA verified contact information. A health and safety evaluation was conducted in all areas accessible to children. OFF LIMIT areas consist of: the first bedroom to the right in the hall and both of the bedrooms to the left in the hall. LPA observed a 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There is a small kids pool in the backyard. Licensee acknowledged that the pool must be dumped immediately after use, and 100% supervision is required while in use.


Staff records were reviewed. Required postings, a current roster, disaster drill log, proof of immunization's were observed. Current in person EMSA CPR and First Aid certification was verified and expires 10/2022. AB 1207 Mandated Reporter Training was verified and expires 1/2022.
A sample of children’s records were reviewed.

Report continued on 809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Rosie Pitts
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: VALLEJO, MARICRUZ
FACILITY NUMBER: 343623142
VISIT DATE: 06/18/2021
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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.

LPA discussed Effects of Lead Exposure, PIN 20-24-CCP Safe Sleep Regulations, and COVID-19 Safety guidelines. LPA provided the following link:http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the Licensee to subscribe to the distribution list and receive Quarterly Updates.


This facility evaluation report was reviewed and discussed with Licensees. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensees were encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signatures on this form acknowledges receipt of this form.

In the areas that were evaluated, No Title 22 Deficiency cited.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Rosie Pitts
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC809 (FAS) - (06/04)
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