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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624759
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:05:51 PM

Document Has Been Signed on 04/26/2023 12:05 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HERNANDEZ, ANNABELFACILITY NUMBER:
343624759
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
04/26/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Annabel HernandezTIME COMPLETED:
12:15 PM
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At 11:35 a.m. on Wednesday, July 27th, 2022, Licensing Program Analsyts (LPAs) Karyn Guerra and Eduardo Barragan met with Licensee, Annabel Hernandez, for the purpose of an unannounced case management - licensee initiated inspection. Licensee requests a change in capacity from 8 to 14 children. A fire clearance was received by the department and is on file. Today's census consisted of 3 preschool children supervised by Licensee and adult assistant.

All individuals subject to criminal background review have obtained a criminal record clearance. 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.

A health and safety inspection was conducted in all areas accessible to children. Off-limit areas consists of the entire main house and front and backyard space. LPA observed current EMSA CPR certification for Licensee and assistant. Licensee observed a fire extinguisher in the home that meets regulatory standards, and functioning smoke and carbon monoxide detectors.

LPA discussed ratios for a large capacity, and documents required for staff or adult assistants. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information.

report continued on 809-C.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HERNANDEZ, ANNABEL
FACILITY NUMBER: 343624759
VISIT DATE: 04/26/2023
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In the areas that were evaluated, no deficiencies were observed at the time of the visit. This facility evaluation report was reviewed and discussed with the licensee, Annabel Hernandez. A Notice of Site Visit was provided and shall remain posted for 30 days for parental review.

Effective today, 4/26/2023, the facility is approved for a large capacity to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in transitional kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of two years. Licensee understands that when there is no assistant present, the facility reverts back to the ratios of a small capacity.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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