384004508-11-28-2022-05-CC-JYEE-CLLRNE-20221128121012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004508
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:10:21 PM

Document Has Been Signed on 11/28/2022 12:10 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ACOSTA, MELVA LUCIA		FACILITY NUMBER:	384004508
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 2	DATE:	11/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Melva Lucia Acosta		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yee conducted an unannounced, Required - 1 year inspection today. The purpose of the inspection was explained. Present at the facility are the licensee, Melva Lucia Acosta, and 2 children (1 infant and her 23 month old son). During the visit, her son left with his grand-father and another child arrived. Current residents in the home are Melva, her husband and their 12 yr old son, 8 yr old daughter and 23 month old son. The facility personnel summary report was reviewed with Melva and she said it is current. Hours of operation are Monday to Friday from 8:00 am to 5:00 pm. The licensee speaks limited English, the licensee's husband helps with the translation over the phone. LPA also used google translation and LanguageLink for this visit. *DAY CARE AREAS:* Playroom (Living Room), Bathroom #1 and Hallway. The remaining areas of the house are off-limits. LPA observed the home to be in good repair with proper temperature and ventilation. There are a variety of age-appropriate toys and equipment in the home which were in good condition. All cleaning supplies, poisons, and other chemicals were stored inaccessible to children behind child-safety locked cabinets. The facility has a working smoke detector, carbon monoxide detector, and a fully charged fire extinguisher, size 2A10BC. Per Licensee, there are no guns or weapons in the home. LPA reviewed all 1 child record and LIC9227 is not on file. LPA advised her to update the file. A blank copy of LIC9227 was provided during the inspection. Continue next page.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ACOSTA, MELVA LUCIA	FACILITY NUMBER: 384004508
	VISIT DATE: 11/28/2022

NARRATIVE

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Licensee's Pediatric First Aid/CPR is current until 10/02/2023. Per licensee all her children are infants. She said it's hard to practice Earthquake drill and fire drill with them. However, she is aware she needs to practice Earthquake drill and fire drill with the children once every 6 months and will keep a log sheet.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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 review AB 1207 with the Licensee. As of January 1, 2018, all staff members are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. The licensee has completed AB1207 on 07/10/2021.

LPA discussed the safe sleep regulations with licensee 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 licensee 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. A sample infant sleep chart was provided.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

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