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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283009852
Report Date: 06/20/2022
Date Signed: 06/20/2022 05:58:06 PM

Document Has Been Signed on 06/20/2022 05:58 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MORA, EVELYN FCCHFACILITY NUMBER:
283009852
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Evelyn MoraTIME COMPLETED:
04:35 PM
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A required - 1 year inspection was made to the facility by Licensing Program Analysts (LPA) Leticia Rosales-Meza. A review of staff records on 06/20/22 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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. There are currently two living in the home.

During today’s inspection the home and grounds were toured. The licensee was supervising one infant, and one preschool child, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30 AM to 5:00 PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home is the master bedroom, and was made inaccessible by means of door knob slip cover and key locked door. The home was clean and orderly, and was at a comfortable indoor temperature of 68 degrees Fahrenheit. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 02/2024. The licensee's CA mandated reporter training certificate expires July 2023. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Licensee stated there are no poisons in the home. The requirement that poisons be stored in a space locked with a key lock/combination lock is reviewed. The fireplace in the living room has been made inaccessible with a board. Mrs. Mora stated the fireplace is not used at all. There is a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2-A, 10:BC. The licensee has conducted an emergency drill within the past six months, most recent Fire drill was documented on 02/12/22. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the front yard and deck as the outdoor play area and it is completely fenced. The backyard and studio are "off limits". The studio has a separate address and a separate entry, driveway to the studio. (Continue to LIC 809-C)
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MORA, EVELYN FCCH
FACILITY NUMBER: 283009852
VISIT DATE: 06/20/2022
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No bodies of water were observed. Five children's (C1 and C5) records were reviewed at 2:10 PM; required emergency information was observed to be on file.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.



Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Evelyn Mora.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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