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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911103
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:08:37 PM

Document Has Been Signed on 02/10/2022 12:08 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:COSTA, KIMBERLY FAMILY CHILD CAREFACILITY NUMBER:
503911103
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee Kimberly CostaTIME COMPLETED:
12:20 PM
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On 02/10/2022, Licensing Program Analyst (LPA), Luisa Gavoutian, conducted an unannounced Annual Inspection. LPA was greeted by Licensee Kimberly Costa who accompanied LPA on a tour of the home, inside and outside, as shown on the facility sketches (LIC 999A) provided. Also present was a fingerprint-cleared live-in adult relative/assistant. Present during today’s inspection were seven children. The areas of the home that are accessible to the daycare children are the living room, kitchen, bathroom, and fenced backyard. “Off-limits” rooms are made inaccessible by doorknob spinners.

One dog and one cat were observed during today’s inspection; Licensee is aware of the safety of children around animals. There are no bodies of water in this home. Licensee stated there are no firearms in this home. All poisons are kept in a locked storage area. LPA observed shampoo and body wash in the shower and an unopened container of hand sanitizer in the bathroom that is used by children. Licensee moved the items during today's inspection and made them inaccessible to children. There is no fireplace. There is a working fire extinguisher, smoke detector and carbon monoxide indicator. The home has adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment were observed.

Adequate supervision is being provided during this inspection, including to napping infants. This facility is following appropriate COVID-19 safety guidelines as set forth by the California Department of Public Health for child care providers. Children are supervised when outside in the play area and there are no hazards to children present. Capacity as specified on the license is being maintained. Fire drills are conducted and documented at least once every six months. A current roster of children is maintained.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alice Juarez
LICENSING EVALUATOR NAME: Luisa Gavoutian
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 02/10/2022
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There is a working telephone and cellphone number was verified. LPA reviewed a sample of children’s files, which were all complete with emergency information as required. LPA observed Child 1 present in care today. Licensee stated that Child 1 is enrolled in and attending kindergarten, but Licensee did not maintain documentation verifying Child 1's enrollment and attendance in kindergarten, as required. During today's inspection, Licensee was able to get in touch with Child 1's parent who confirmed that Child 1 is enrolled in and attending kindergarten. Licensee will obtain and maintain documentation in Child 1's record. Licensee maintains documentation of immunizations for influenza, pertussis, and measles for herself and staff. Licensee’s Pediatric CPR/First Aid are current expiring on 02/01/2023. Licensee’s Mandated Reporter training certificate was completed on 10/17/2021. LPA reviewed Staff 1's and Staff 2's file and found that they have not completed the mandated reporter training. LPA advised that Staff 1 and Staff 2 should complete the training as soon as possible and renew training every two years following the initial date of completion. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advanced notice. Days and hours of operation are Monday – Friday; 7:30 a.m. – 5:30 p.m.

LPA & Licensee discussed the Community Care Licensing (CCL) website (www.ccld.ca.gov) which provides access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, Forms, and Regulations. Licensee stated she is receiving PINs and updates through email. LPA discussed infant items permitted in Family Child Care Homes and left a visual handout. LPA provided Licensee with the “Effects of Lead Exposure” brochure in accordance with AB 2370, Chapter 676, Statutes of 2018.

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.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alice Juarez
LICENSING EVALUATOR NAME: Luisa Gavoutian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COSTA, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911103
VISIT DATE: 02/10/2022
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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.

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

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited. Exit interview conducted and report was reviewed with the licensee Kimberly Costa.

A notice of site visit was given and must remain posted for 30 days.

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/process.
SUPERVISORS NAME: Alice Juarez
LICENSING EVALUATOR NAME: Luisa Gavoutian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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