<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622751
Report Date: 12/08/2021
Date Signed: 12/08/2021 10:04:45 AM

Document Has Been Signed on 12/08/2021 10:04 AM - 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:MARTINEZ, ELIZABETHFACILITY NUMBER:
393622751
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 11CENSUS: 4DATE:
12/08/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Elizabeth MartinezTIME COMPLETED:
10:10 AM
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
On 12/08/2021 at 9:28 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted an unannounced case management inspection and met with Licensee, Elizabeth Martinez. The purpose of today's visit was to do an increase of capacity inspection. Licensee has requested a capacity increase to 14 children. A fire clearance has been approved by Stockton Fire Prevention fire marshal on 12/12/2021

LPA Birk-Miller observed a working 2-A-10-BC fire extinguisher and a working smoke and carbon monoxide detector. LPA observed the newly installed fire pull system. Licensee stated there are no new residents in the home since being licensed and all adults who require fingerprint clearances have received the required clearance. A healthy and safety inspection was done of the inside and outside of the home.

The off limits areas include: all bedrooms and storage building outside on left side of house. During the inspection the Licensee asked the LPA to place the spare bedroom on-limits. LPA inspected the room and as of today the spare bedroom will be placed on-limits. The licensee understand that if an off limits area is to become on limits or vice versa she will need to contact her LPA. During the inspection the LPA reminded the Licensee of the safe sleep regulations and the Licensee stated she has been following the regulations.

Effective today 12/08/2021, LPA is granting a license 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 kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years. When there is no assistant present, the facility will revert back to the small capacity.

An exit interview was conducted. Notice of site visit given and posted. This shall be posted for 30 days.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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