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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500105
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:16:34 PM

Document Has Been Signed on 11/19/2024 12:16 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MORENO, DOLORESFACILITY NUMBER:
394500105
ADMINISTRATOR/
DIRECTOR:		MORENO, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 807-0063
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/19/24, Licensing Program Analyst (LPA) Carla Polanco met with Licensee Dolores Moreno for the purpose of an unannounced annual inspection. There were seven children present at the start of inspection, being supervised by Licensee and a qualified assistant. Licensee's operating hours are Monday through Friday from 5:00 AM to 5:00 PM. Licensee speaks Spanish, the visit was conducted in Spanish and the report was translated by LPA.

All adults subject to criminal background review have obtained criminal record clearance. 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.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the side yard, entire upstairs and the master bed and bath. LPA observed the required postings and a working phone. 2A10BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives were inaccessible to children in care. LPA observed playroom area with age appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. Licensee stated there are no weapons in the home. Outdoor play space is fenced. There are no bodies of water on the premises.

Continues on LIC809-C......
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MORENO, DOLORES
FACILITY NUMBER: 394500105
VISIT DATE: 11/19/2024
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Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months, last drill was conducted in 10/2024. Licensee's immunization records are available in the facility file. Current EMSA pediatric CPR and First Aid certification was verified and expires 03/2025 and Child Care Provider Mandated Reporter certification was verified and expires 09/2025. Licensee does not carry liability insurance; Liability insurance waiver was observed in children’s files.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA observed 15 min infant napping log for infants 24 months and under. LPA observed copies of LIC 9227 Individual Sleeping Plan for infants under 12 months.

This provider is not currently providing Incidental medical Services (IMS) to children in care.

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. Licensee states that she receives the PIN's.

Exit interview was conducted and the report was reviewed with the licensee. A notice of site visit was provided and posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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