Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407813
Report Date: 12/11/2017
Date Signed 12/11/2017 09:14:52 AM

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:PEREZ, SILVIAFACILITY NUMBER:
073407813
ADMINISTRATOR:PEREZ, SILVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 566-6005
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:14CENSUS: 9DATE:
12/11/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Silvia PerezTIME COMPLETED:
09:30 AM
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An unannounced Annual/Random site inspection was conducted by LPA Susan Neeson. Met with Silvia Perez, Licensee. Also present is her Mother and another helper. She resides here with her two high school age children and her partner. There are five adults fingerprint clear and associated with the facility. CPR and First Aid are current through May 2019 for Silvia and her three helpers. There are four infants and 5 preschool age children present.

The home has 3 bedrooms and two bathrooms, kitchen and living room upstairs. The upstairs one bathroom is used for children. Day care is done in the downstairs areas, 3 bedrooms and one bath and the kitchen. All rooms have been outfitted with toys and equipment for children. There are mats for napping. The yard has toys and equipment for children. All toys and equipment are in good condition. The fire extinguisher 2A 10 BC is currently charged and the smoke alarm works. There is also a a carbon monoxide detector. There are no hazards observed in the day care areas. downstairs kitchen area. All electrical outlets are covered. The home has central heating. Detergents, cleaning products, medicines and cosmetics and sharp knives are all stored in the upstairs off-limits areas. There are no bodies of water. There is a fireplace in the upstairs area which has a barricade and there is a large TV in front of it. There is an aquarium with fish in the day care area and there is an other aquarium with one small tortoise. Blue immunization forms were issued.

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.gov

Incidental Medical Services were discussed with Silvia Perez. She is not providing IMS at this time. She will submit an updated plan of operation if in the future they provide any IMS to a child in care.

Silvia Perez states that there are no guns or firearms in the home.

No deficiencies are observed. An exit interview was given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2017
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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