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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585408152
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:09:35 AM

Document Has Been Signed on 06/29/2022 11:09 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:HERNANDEZ, TERESITA FAMILY CHILD CARE HOMEFACILITY NUMBER:
585408152
ADMINISTRATOR:HERNANDEZ, TERESITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 315-5843
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
06/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresita HernandezTIME COMPLETED:
11:10 AM
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On 6/29/2022 at 10:45am, Licensing Program Analyst (LPA) Laura Chavez conducted pre-licensing inspection in response to an application for a change of location, the requested capacity is 14. LPA met with applicant, Teresita Hernandez. The facility will operate Monday-Saturday, 3:30am to 7:30pm. The residence is a three bedroom/ two bath single story home. Two adults currently live in the home. The home and yard were toured, and the facility sketch was verified. The following areas will be off limits to children: All three bedrooms, master bathroom and garage. These areas have been made inaccessible by means of door knob covers. During todays inspection no poisons were observed in the home. The licensee understands that any poison brought into the home shall be locked as required. The home is equipped with a working smoke detector and fire extinguisher rated at least 2A10BC. The children will use the backyard as the outdoor play area. The backyard is completely fenced. There is no pool, spa, pond, fountain, or any other body of water on the premises. LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted. The licensee 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.

Prior to licensing the home the following is needed:
1. Fire Inspection Approval
2. Proof of current training Preventative Health Practices
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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