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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500700
Report Date: 11/01/2022
Date Signed: 11/01/2022 01:57:10 PM

Document Has Been Signed on 11/01/2022 01:57 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:CUSTODIO, ALMA L. & ALMAFACILITY NUMBER:
344500700
ADMINISTRATOR:CUSTODIO, ALMA L. & ALMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 271-3472
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alma CustodioTIME COMPLETED:
02:15 PM
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On 11/01/2022, Licensing Program Analyst Katy Maestas (LPA) met with Applicants Alma L. Custodio (A1) and Alma Custodio (A2) for the purpose of a pre-licensing inspection. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). LPA provided the Entrance Checklist to A1. Also present in the FCCH was A1's adult sibling. A2's primary language is Spanish; A1 acted as a translator for all required information. All individuals subject to criminal background review have obtained a criminal record clearance which was verified by LPA accessing Guardian. A1 & A2's tentative hours of care are Monday through Friday, from 7:00 AM until 6:00 PM. A1 & A2 do not intend on providing overnight or weekend care.

A fire clearance was granted on 10/11/2022 for the FCCH. A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a two story house with a tri-level first floor. The first level of the home consists of a living room, and the second level consists of a dining room, kitchen, and eating nook. The third, lower level of the first floor consists of the play room, bathroom, bedroom, laundry room and access to the garage. The second floor of the FCCH consists of 3 bedrooms, bathroom, master bedroom and bathroom. LPA verified that toxic and hazardous items were inaccessible to children in care. LPA observed a fireplace in an upstairs bedroom which is barricaded by a glass door. The FCCH has three stairways; LPA observed 1 stairway to be properly barricaded by a baby-gate. A1 and A2 understand that the other 2 stairways must also be barricaded for LPA to issue a license. A1 and A2 will purchase and install a baby-gate on both stairways. A1 will email a picture of the gated stairways to LPA by 11/07/2022. LPA observed a railing that separates the eating nook and the playroom. A1 and A2 understand that the railing must be covered with mesh, net or fabric to deter children from the railing. A1 will email a picture of the covered railing to LPA by 11/07/2022. The outdoor play area was toured which includes a covered patio, backyard, and side yards. LPA verified that the entirety of the backyard is fenced-in and walked the perimeter to ensure the safety of the fence and gates. LPA did not observe any pool, spa nor water feature. Applicant stated that she owns three indoor/outdoor cats. Continued on 809-C
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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: CUSTODIO, ALMA L. & ALMA
FACILITY NUMBER: 344500700
VISIT DATE: 11/01/2022
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The OFF-limits areas of the FCCH are the unfenced front yard, garage, living room, dining room, kitchen, laundry room, and the entirety of the second floor. A1 understands that OFF-limits areas must remain inaccessible to children in care.

A functioning smoke and carbon monoxide detector was observed on the first floor and both were tested for functionality. LPA observed cleaners stored in the kitchen, under the sink and behind a child safety lock. LPA observed cleaners and detergents stored in the laundry room; some chemicals were on the top shelves and out of reach of children in care and others were in a cabinets that was closed with a child safety lock. LPA observed 2 21007883A fire extinguishers that had been serviced and approved by the Consumes Fire Department. LPA observed a first aid kit which is stored in the closet off of the playroom. A1 stated there are no firearms nor weapons in the home.

LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their Mandated Reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English. A1 and A2 have current Mandated Reporter Training Certificates which will expire on 07/31/2023. Current Pediatric CPR and First Aid training was verified and will expire on 07/05/2024. The completion of Preventative Health and Safety training including nutrition and lead exposure was verified before the inspection. Proof of required immunizations for A1 and A2 was also verified before the inspection.


LPA discussed the Safe Sleep Regulations with A1 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 A1 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. Continued on 809-C
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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: CUSTODIO, ALMA L. & ALMA
FACILITY NUMBER: 344500700
VISIT DATE: 11/01/2022
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LPA discussed the requirement to check and log infant napping every 15 minutes for children under 24 months old. LPA provided a copy of the LIC 9227, Individual Sleeping Plan, to be completed for infants under 12 months.

Incidental Medical Services (IMS) policy was discussed with A1. 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.

A1 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. A1 understands that her adult child will have to have cleared fingerprints before residing in the FCCH.

A1 understands that licenses are not transferable, and once licensed, Licensees A1 and A2 must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.


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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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: CUSTODIO, ALMA L. & ALMA
FACILITY NUMBER: 344500700
VISIT DATE: 11/01/2022
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A1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with A1 the LIC 311D Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted. A1 understands that fire drills must be conducted and documented once every six months.


As of today, 11/01/2022, A1 and A2 will be approved for a Provisional Large Family Child Care Home license to serve 12 children (when there is an assistant present) with no more than 4 infants, or a capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without an assistant, the ratios revert to those for Small Family Child Care Home. Provisional license will expire 11/07/2022.

LPA will grant A1 and A2 a regular license once the required documentation is submitted to LPA:


1. Photograph of 2 barricaded stairways

2. Photograph of covered railing between eating nook & playroom

3. Photograph of a child lock on the medicine cabinet in the lower level bathroom

An exit interview was conducted, and the report was reviewed with A1. Licensee Appeal Rights were provided. A Notice of Site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements will result in an immediate civil penalty of $100.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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