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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500643
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:37:58 PM

Document Has Been Signed on 09/08/2023 03:37 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AYALA, ANGELICAFACILITY NUMBER:
394500643
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Angelica AyalaTIME COMPLETED:
03:45 PM
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On 09/08/2023 at 1:15 PM, Licensing Program Analyst (LPA) Tiffanie Diep met with Licensee Angelica Ayala for the purpose of an unannounced annual inspection and to change Licensee's backyard from off limits to on limits, and Licensee guided LPA on a tour of the home. Licensee provided proof of control of property. LPA observed six children present in the home with Licensee. Licensee's operating hours are Monday through Friday from 4:45 AM to 5:30 PM. LPA verified that annual fees are current.

All individuals subject to a criminal record review have obtained a criminal record clearance. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of five days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

A health and safety inspection of the home’s interior and exterior was conducted in all areas accessible to children. The off-limits areas in the home include the second right bedroom, master bedroom/bathroom, garage, both side yards, and front yard. LPA observed the required postings and a working phone. LPA observed a 2A10BC fire extinguisher meets regulations and verified dual smoke and carbon monoxide detectors were functional. LPA toured the kitchen area and verified knives were inaccessible to children in care. LPA observed a restroom and verified that toxic and hazardous items were inaccessible to children in care. LPA observed cleaners stored in garage and inaccessible to children in care. LPA observed the playroom with age-appropriate toys for children. Licensee stated there are no weapons in the home. LPA did not observe a fireplace in the home. The backyard was inspected and is surrounded by a wooden fence. LPA walked the perimeter of the backyard and verified that the entire area is fenced in. LPA observed a play structure and trampoline in the backyard. The backyard will be made on limits effective today, September 8, 2023. LPA did not observe bodies of water on the premises.
Continues on 809-C
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AYALA, ANGELICA
FACILITY NUMBER: 394500643
VISIT DATE: 09/08/2023
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Continued from 809 (Page 2)

LPA reviewed five children's files, and LPA observed 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. LPA verified Licensee's immunization records were available in the facility file. Current Mandated Reporter Training certificate was verified and expires on 05/02/2024. Current EMSA pediatric CPR and first aid certification was verified and expires on 05/20/2024.

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. LPA observed 15-minute napping logs for infants under 24 months and a copy of the Individual Sleeping Plan (LIC 9227) for infants under 12 months during the inspection.

This facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information, see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at https://www.ada.gov/resources/child-care-centers/.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AYALA, ANGELICA
FACILITY NUMBER: 394500643
VISIT DATE: 09/08/2023
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Continued from 809-C (Page 3)

To improve the quality and value of the new inspection process, a survey may be sent to the e-mail address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE Tool, please send e-mail inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process. Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

There were no deficiencies cited at this time. An exit interview was conducted and report was reviewed with the licensee, Angelica Ayala. During the exit interview, Licensee confirmed that there are no registered sex offenders (RSO) living in the facility and LPA completed the RSO profile in the Field Automation System. A notice of site visit was given to Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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