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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500643
Report Date: 08/19/2022
Date Signed: 08/19/2022 12:21:18 PM

Document Has Been Signed on 08/19/2022 12:21 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:AYALA, ANGELICAFACILITY NUMBER:
394500643
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Angelica AyalaTIME COMPLETED:
12:40 PM
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On Friday, August 19, 2022, Licensing Program Analyst (LPA) Elvira Sierra met with Applicant, Angelica Ayala for the purpose of an announced pre-licensing inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Facility is a single story home, three bedrooms and two bathrooms. Applicant stated facility hours of operation will be M-F from 05:00 am to 05:00 pm year-round.

A health and safety inspection was conducted in all areas of the home as well as the outdoor area. Off-limits areas will include; Bedroom # 2 and # 3, garage, front yard and driveway. Applicant acknowledged that children may never enter these off-limit areas. Applicant was advised that she must contact Licensing prior to making an off-limits area on-limits and vice versa. Home is clean and appropriately ventilated. Age appropriate toys and reading material were observed. Sufficient napping equipment was observed for the capacity requested. Hazardous cleaning compounds and medications are stored inaccessible and or out of children reach. Safety latches are in use on some kitchen cabinets, bathroom cabinets and drawers. The applicant understands that she must ensure the safety latches are not broken. Facility has a working telephone. Functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher were observed in the home. Applicant stated backyard is under renovation. LPA advised to contact Licensing once renovation is completed to get approval before daycare children can use the backyard.

Applicant stated that she will transport children. Applicant acknowledges that only drivers licensed for the type of vehicle to be operated shall be permitted to transport children in care, the manufacturer's rated seating capacity of the vehicle shall not be exceeded, motor vehicles used to transport children in care shall be maintained in safe operating condition, and all vehicle occupants must be secured in an appropriate restraint system. Applicant provided proof of control of property on today's visit. LPA reviewed the fire drill requirements. The Applicant has certificates of completion for Preventative Health and Safety training including CPR/First Aid (expires: 05/24 and Mandated Reporter Training (expires: 05/02/2024).
At this time, the Applicant does not carry liability insurance. LPA explained about obtaining a $300,000 annual aggregate/$100,000 per occurrence liability insurance policy. Applicant understands that until a policy is obtained, she must use the affidavit. ------Report continues on subsequent page 809C--
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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: AYALA, ANGELICA
FACILITY NUMBER: 394500643
VISIT DATE: 08/19/2022
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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.

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 the 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

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.

Report continues on subsequent page 809C--
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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: AYALA, ANGELICA
FACILITY NUMBER: 394500643
VISIT DATE: 08/19/2022
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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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Small Family Child Care License is approved and will be effective as of today, 08/19/22.
For a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Kindergarten or above and 1 child at least age 6.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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