Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393616949
Report Date: 01/05/2016
Date Signed 01/05/2016 02:43:23 PM

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:ALVARADO, JAZARYFACILITY NUMBER:
393616949
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
01/05/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jazary AlvaradoTIME COMPLETED:
03:05 PM
NARRATIVE
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(3) Licensing Program Analyst (LPA) Nancy Kyotani met with licensee for Random Annual and an Increase in Capacity visit and toured areas of the home accessible to the children. LPA observed care and supervision of children and ratios. Off-limit areas: Entire upstairs of the home and garage. Licensee acknowledged that children may never enter these off-limit areas. The backyard is fenced and licensee acknowledges that children may never be left unsupervised in an unfenced area of the yard. There are no bodies of water on the property. Adult residents have criminal record clearances.

LPA observed current CPR/First Aid certificates (expire on 9/9/17) , inaccessible and locked poisons, fire extinguisher and smoke detector meet regulation. Fireplace is screened, cleaning materials and medications are inaccessible, stairs are barricaded, there is a working telephone, and toys appear to be safe. Licensee stated there are no weapons in the home, and LPA did not observe children left in parked cars.

LPA discussed departments Inspection Authority and reviewed children and staff files. LPA reviewed the following protocols: Shaken Baby, SIDS and criminal record requirements. LPA provided the Licensing Agency website (www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.

LPA also explained the Zero Tolerance and immediate Civil Penalty regulation deficiencies and citations, seat belt/booster seat laws, Healthy Beverages Act, the Religious/Personal Beliefs Exemption for Immunization, smoking prohibition and carbon monoxide detector requirement and Incidental Medical Services (IMS) requirements.

No Title 22 Deficiencies were cited during this visit.
LPA will recommend a license to serve maximum capacity 12 children: no more than 4 infants. Capacity 14 children: No more than 3 infants, 1 child in kindergarten or elementary school and 1 child at least age 6.
SUPERVISOR'S NAME: Monica R FiliceTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Nancy KyotaniTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2016
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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