Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407702
Report Date: 02/17/2016
Date Signed 02/17/2016 12:03:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PACHECO, VALERIAFACILITY NUMBER:
073407702
ADMINISTRATOR:PACHECO, VALERIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 504-2114
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:14CENSUS: 9DATE:
02/17/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Valeria PachecoTIME COMPLETED:
12:15 PM
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(1) Licensing Program Analyst Belinda Devall met with licensee Valeria Pacheco for an UNANNOUNCED RANDOM VISIT. Present for this visit was her fingerprint daughter Karen, fingerprint cleared spouse Alfredo, 3 infants and 6 preschoolers. The home was toured to conduct a Health and Safety Inspection.
The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room which is converted to a large playroom for the children, bedroom #1, bathroom in the hallway, dining area, back patio and backyard. The remainder of the home is OFF LIMITS which will be inaccessible by closed and/or locked doors, safety gates and visual supervision. The outdoor play area is free from defects or dangerous conditions and is fully fenced. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The licensee CPR and First Aid certificate is current and expires 12/2016. The fireplace is blocked to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year.
The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. Incidental Medical Services (IMS) were discussed with the licensee. The licensee is not providing IMS at this time. Licensee will submit a plan of operation if in the future they provide any IMS services to a child in care. Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.ca.gov
There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given, posted by LPA and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Belinda DeVallTELEPHONE: (510) 725-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2016
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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