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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911287
Report Date: 08/10/2021
Date Signed: 08/10/2021 09:09:54 PM

Document Has Been Signed on 08/10/2021 09:09 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:RIOS, ANA FAMILY CHILD CAREFACILITY NUMBER:
543911287
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Ana Rios TIME COMPLETED:
02:00 PM
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On 08/10/21, Licensing Program Analysts (LPAs), Jose Penate and Stefani Galvan conducted an unannounced Annual Required Inspection and was met by Licensee, Ana Rios. Planned hours of operation are Monday through Saturday from 4:00AM - 6:00PM and as arranged.

LPA toured the home inside and outside and a census was taken. Currently the backyard is off-limits to day-care children. The areas of the home that day care children will have access to are the grand room that includes an adjacent bathroom. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition at this home. No poisons were observed during the inspection.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. The home has working telephone service and LPA confirmed the phone number is (559) 615-0161.

Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed by licensee, while asleep in the grand room. Infants up to 12 months of age are placed on their backs for sleeping.

Continued on LIC 809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: RIOS, ANA FAMILY CHILD CARE
FACILITY NUMBER: 543911287
VISIT DATE: 08/10/2021
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s pediatric CPR/First Aid is current and will expire 9/15/2021. Mandated Reporter has been completed and will expire on 11/6/21. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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