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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846208
Report Date: 04/26/2022
Date Signed: 04/28/2022 09:16:02 AM

Document Has Been Signed on 04/28/2022 09:16 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SANDOVAL FAMILY CHILD CAREFACILITY NUMBER:
364846208
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rosalina SandovalTIME COMPLETED:
12:00 PM
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On date and time listed, Licensing Program Analysts (LPAs) Laura Mejorado and Aman Sharma arrived at the facility to conduct a pre-licensing inspection. The Applicant was previously licensed at another location. Present during this inspection was Applicant Rosalina Sandoval. LPA toured the facility, inside and out and the following was observed and/or discussed:

Normal days and hours of operation: Monday - Saturday, 6:00am - 11:00pm
OFF-LIMIT AREAS INCLUDE: Garage, Bedroom 2, 3, 4, Bathroom #2, left side of house, and front yard

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection. Fire extinguisher, smoke detector and carbon monoxide detector are in working order.
· All hazardous items are inaccessible
· Storage of poisons/toxins are inaccessible to children and locked
· Weapons are not present/stored according to Title 22. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Single story home
· Verification of control of property on file (Mortgage Statement)
· Mandated Reporter Training completed on 03/31/22
· Pediatric CPR and First Aid Card - expire 05/04/22 (Applicant has scheduled appointment to renew)
· Health & Safety Certificate - completed on 04/03/22

· No bodies of water at this time. Applicant understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SANDOVAL FAMILY CHILD CARE
FACILITY NUMBER: 364846208
VISIT DATE: 04/26/2022
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· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time
· The Applicant was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 4/26/22 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

The following was discussed with the applicant(s):

- LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted
- Entrance Checklist was provided to the Applicant.
- Pre-Licensing Visit Packet was provided
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited
- LPA discussed the safe sleep regulations with Applicant 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 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.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SANDOVAL FAMILY CHILD CARE
FACILITY NUMBER: 364846208
VISIT DATE: 04/26/2022
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Incidental Medical Services (IMS) policy was discussed. 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

- 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, 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.



- 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.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

Before licensure, the following needs to be corrected/completed:

- Licensee agrees to submit updated Facility Sketch to include all areas of the home
- Licensee agrees to submit original Application
- Licensee agrees to place a gate on the left side of the home making that area inaccessible to children
- Licensee agrees to remove all hazardous items from the backyard play area (wood/tools)
- Licensee agrees to place a child proof latch on the dresser in bedroom #1 and ensure room is clear of any hazards
- Licensee agrees to post required documents and submit proof
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SANDOVAL FAMILY CHILD CARE
FACILITY NUMBER: 364846208
VISIT DATE: 04/26/2022
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Once all corrections have been verified, the application for a Small Family Child Care Home will be submitted for approval with a maximum capacity of 6, or 8 with parent notification. Applicant advised that all corrections are due within 30 days or the application may be withdrawn.

Applicant, Rosalina Sandoval, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the Applicant Rosalina Sandoval.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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