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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500105
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:19:18 AM

Document Has Been Signed on 11/19/2021 10:19 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:MORENO, DOLORESFACILITY NUMBER:
394500105
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/19/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dolores MorenoTIME COMPLETED:
10:30 AM
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On Friday, November 19, 2021, at 08:30 AM, Licensing Program Analyst (LPA) Elvira Sierra conducted a Case Management visit for the purpose of increasing the maximum capacity from 8 to 14 children. Fire Safety Inspection Clearance was granted on November 11, 2021, for a total capacity of 14 children. Facility hours of operation are from M-F from 06:00 am to 06:00 pm. All individuals subject to criminal background review have obtained a criminal record clearance. Present in the facility were Licensee's assistant and Licensee's husband. Licensee was not present during the inspection. Upon arrival no children were present, one child arrived later during the inspection.

At 09:00 am, a health and safety inspection of all areas accessible to children was conducted and the following was observed. Home appears orderly and suitable for children. The Off-limits areas has not changed and include; Entire upstairs level, garage, right side of the backyard, and front yard. Current CPR/First Aid certificate was observed for Licensee's Assistant and Licensee and expires on 04/03/2023. Posted License, Parent's Rights, Emergency Disaster Plan, Roster of the enrolled children, and Fire Drill Log are all being maintained. The fireplace in the living room is appropriately barricaded to prevent access by children.Stairs leading to the second floor are appropriately barricaded. Hazardous items were stored inaccessible to children in care. Safety latches are in use in the kitchen and bathroom cabinets. Fire extinguisher (2A10BC), carbon monoxide and smoke detector meet regulation. Toys appear to be safe and age appropriate. The backyard is fenced for supervision. There are no weapons or bodies of water on the premises.

Staff 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.

Report continues on subsequent page 809C--

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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: MORENO, DOLORES
FACILITY NUMBER: 394500105
VISIT DATE: 11/19/2021
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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 the safe sleep regulations with staff 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 staff 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.

Capacity increase is approved as of today, November 19, 2021. The facility is licensed to serve a MAX. CAP(WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.



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

Exit interview conducted and report was reviewed with the Licensee's Assistant and Licensee's husband.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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