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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500274
Report Date: 07/08/2021
Date Signed: 07/08/2021 02:33:01 PM

Document Has Been Signed on 07/08/2021 02:33 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:LOPEZ, PAULINAFACILITY NUMBER:
344500274
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/08/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Paulina LopezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Fabiola Diaz met with licensee Paulina Lopez on 7/08/2021 for the purpose of an unannounced annual random inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Census at the time of inspection was 2 children and 3 infants. COVID-19 precautionary measures were implemented during this visit.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include: all upstairs, kitchen, and garage. LPA observed the required postings and a working phone. LPA observed a working 2A10BC fire extinguisher and functioning smoke and carbon monoxide detectors (which was a dual detector). Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Cleaning supplies and hazardous items were stored out of the reach of children. Play toys and equipment were in safe conditions. LPA observed stairs to be barricaded according to Title 22. The facility did not have a fireplace.

LPA observed children's files to be complete. LPA observed a complete children's roster and discussed that a fire drill should be conducted at least once every six months. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu were observed. Current in-person EMSA pediatric CPR and First Aid certification was observed for licensee and expires 7/16/22. LPA observed a current Child Care Provider Mandated Reporter certificate for licensee and expires 3/24/22; LPA informed licensee the training shall be done every two years. LPA observed a copy of the liability insurance for the home day care facility.

Report continues on 809-C
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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: LOPEZ, PAULINA
FACILITY NUMBER: 344500274
VISIT DATE: 07/08/2021
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LPA discussed the Incidental Medical Services (IMS) policy with licensee. 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.

Licensee stated she is signed up to receive the Provider Information Notices- PINs. LPA provided and discussed the Safe Sleep in Child Care PIN and regulations and Effects of Lead Exposure brochures. LPA discussed the sleeping log required for sleeping infants.

This facility evaluation report was reviewed and discussed with Licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.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. Licensee's signature on this form acknowledges receipt of this form. No Title 22 deficiencies were cited on today's date.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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