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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009827
Report Date: 10/01/2021
Date Signed: 10/01/2021 10:35:37 AM

Document Has Been Signed on 10/01/2021 10:35 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,
, CA
FACILITY NAME:CASARRUBIAS-MAZARI, LIZBETH FCCHFACILITY NUMBER:
483009827
ADMINISTRATOR:CASARRUBIAS-MAZARI LFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 721-2626
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Lizbeth Casarrubias- Mazari, LicenseeTIME COMPLETED:
10:50 AM
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A Required- 1 year inspection was made to the facility by Licensing Program Analyst (LPA) Kevin O'Connell. A review of staff records on 10/01/21 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are three adults adult living in the home.
During today’s inspection the home and grounds were toured.
The licensee and an assistant were supervising nine children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are Monday - Friday; 06:00am - 06:00pm and Saturday 6am to 6pm as needed.
The three bedrooms and two bathrooms on the upper level, laundry room on the lower level and the garage are off limits to the children. These areas have been made inaccessible by means of door knob covers and children's safety gates. The staircase in the home is barricaded with a child safety gate.
The back yard is fully fenced and used for outdoor play. The home was clean and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The Licensee has current pediatric CPR and First Aid certifications which expires 11/22. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Licensee states that there are no poisons but has the capacity to key lock them in a cabinet in the garage.
The fireplace is barricaded with a four foot rack of bins filled with children's toys. There is a working smoke detector & carbon monoxide detector and at least one 2A 10BC charged fire extinguisher. Licensee states that there are no firearms or dangerous weapons and none were observed. The Licensee states that there are no pools, spas, or water features and none were observed.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Kevin O'Connell
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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,
, CA
FACILITY NAME: CASARRUBIAS-MAZARI, LIZBETH FCCH
FACILITY NUMBER: 483009827
VISIT DATE: 10/01/2021
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Two staff files were reviewed at 09:55am for Mandated Reporter Certificates and immunizations and all were current. Nine children's records were reviewed at 10:05am; required emergency information cards were observed to be on file. There is one child that may need Incidental Medical Services at this time. (Epi-Pen) File was checked for consent form and instructions. Licensee states that she will provide a written Plan of Operation to CCL within seven days.
The following information regarding ADA was provided: US Department of Justice 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, www.ada.gov/childqanda.htm. This report was reviewed and discussed with the licensee.
All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

No Title 22 violations were cited during today's inspection.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Kevin O'Connell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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