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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500502
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:21:54 PM

Document Has Been Signed on 11/05/2021 02:21 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:SANDOVAL, TONIFACILITY NUMBER:
574500502
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Toni Sandoval TIME COMPLETED:
02:30 PM
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On November 5, 2021 Licensing Program Analyst (LPA) Stacey Williams met with Applicant Toni Sandoval for the purpose of a pre-licensing inspection. Applicant’s infant child was present in the home during the inspection. Criminal record clearances were verified.

LPA and Applicant toured the single -story home. The facility consists of 3 bedrooms, 1 bathroom, living room, and kitchen. The entire home will be on limits.

Applicant rents the home. A copy of the lease is on file. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. LPA provided blank forms required for staff records as well as for children's records including LIC 9227- Individual Infant Sleeping Plan. At the left entry of the facility, LPA observed a licensing document area where Parent's Rights form, Emergency Disaster, and the Facility Sketch is posted. This is the designated area where Licensing forms/posters will be placed for parental review. LPA and Applicant discussed Safe Sleep Regulations and Covid-19 Guidance for Childcare Providers. Applicant understands the smoking prohibition for childcare.

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

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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: SANDOVAL, TONI
FACILITY NUMBER: 574500502
VISIT DATE: 11/05/2021
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LPA and Applicant continued to tour the home. Kitchen cabinets are properly secured. All medications and knives are stored inaccessible.

LPA observed a 2A10BC fire extinguisher. LPA observed an operational smoke detector and carbon monoxide detector in the home that meet regulatory standards. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction.


Applicant has completed the required AB1207 Mandated Reporter training. Applicant understand that the training must be completed once every two years, training is accessible at www.mandatedreporterca.com. CPR/First Aid certification is current and expires August 2023.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the Applicant can obtain updated licensing information, new regulations and access forms. LPA advised Applicant of their responsibility to stay current in regard to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

This facility evaluation report was reviewed and discussed with the Applicant.

Effective November 5, 2021, Applicant is approved for a license to serve up to either 8 children, two (2) of which must be at least 6 years of age and no more than two (2) may be infants; or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of 2 years.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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