Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620268
Report Date: 05/21/2015 12:00:00 AM
Date Signed 05/21/2015 01:24:02 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:JURAN, MELANIEFACILITY NUMBER:
393620268
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
05/21/2015
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Melanie JuranTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nancy Kyotani met with licensee for a Case Management visit for a Capacity Increase visit and toured areas of the home accessible to the children. LPA observed care and supervision of children and ratios. Off-limit areas: Garage, laundry room and master bedroom. 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. A trampoline is located in the backyard for Licensee's own children's personal use and Licensee acknowledged that she is following the manufacturer's recommended use. Adult residents have criminal record clearances.
LPA observed current CPR/First Aid certificates (expire on 10/25/16) , inaccessible and locked poisons, fire extinguisher and smoke detector meet regulation. Fireplace is screened, cleaning materials and medications are inaccessible, there is a working telephone, and toys appear to be age appropriate. Licensee stated there are no weapons in the home, and LPA did not observe children left in parked cars.

LPA also explained Personal Beliefs Exemption for Immunization, smoking prohibition and carbon monoxide detector requirement.

There were no Title 22 Deficiencies cited during this visit.

Licensee acknowledged that she is aware of the ratio and capacity when there is not an assistant present.

LPA will recommend a license( effective 5/21/15) to serve maximum capacity 12 children: no more than 4 infants. (Licensee did not request/obtain landlord/owner consent to care for the two additional school-age children.)
SUPERVISOR'S NAME: Monica R FiliceTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Nancy KyotaniTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1