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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416044
Report Date: 04/15/2022
Date Signed: 04/19/2022 09:00:05 AM

Document Has Been Signed on 04/19/2022 09:00 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BERNAL, BRENDAFACILITY NUMBER:
434416044
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
04/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brenda BernalTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Elizabeth Berumen conducted an announced Pre-licensing visit and met with Applicant, Brenda Bernal.
Hours of operation are Monday through Friday, 6:00 AM to 9:00 PM. Applicant lives in the home with her husband, Miguel Angel Gomez and their two children ages 11 and 17. Applicant's 17 year old son will be 18 on August 23, 2022. Applicant rents the home and has land lord consent. 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.

The Applicant has completed the health & safety training including nutrition & lead exposure training. Applicant has current CPR & First Aid expiring on 08/07/2022. The Applicant's copies of immunization records are on file. Mandated reporter training was completed on August 14, 2020.
LPA inspected the indoor and outdoor areas of the home. LPA tested the carbon monoxide detector and smoke detector; both proved to be working. Fire extinguisher size 2A10BC was observed. Off limit in the home are two bedrooms (including bathroom in master bedroom) hall closet, laundry closet that is located in bathroom. LPA asked Applicant to place a latch/lock on laundry room closet. No bodies of water were observed. Applicant has a working cell phone (646) 474-2508. No stairs in the home. The backyard is off limits. Applicant plans to fence the front yard and use it as outdoor play space. Outdoor play areas shall be either fenced, or outdoor play areas shall be supervised by the licensee section 102417(g)(5). Applicant states that there are no fire arms or weapons in the home. LPA observed that all poisons, detergents, cleaning compounds and any other items that could pose a danger to children are stored inaccessible. Medication is stored in inaccessible to children. The home is neat and clean with heating and ventilation for safety and comfort. Toys and play equipment are safe and in good repair.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: BERNAL, BRENDA
FACILITY NUMBER: 434416044
VISIT DATE: 04/15/2022
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LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep web page athttps://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. LPA informed Licensee the requirement of practicing fire disaster drills and documenting, once every six months. LPA provided Applicant, with a facility roster.

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.

LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised the Applicant of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.


Exit interview conducted and report was reviewed with the applicant, Brenda Bernal.

A small License (capacity 8) is approved today.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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