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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211221
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:24:54 PM


Document Has Been Signed on 06/06/2023 03:24 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:MILES, MARY & TARVER, MITCHELLFACILITY NUMBER:
010211221
ADMINISTRATOR:MILES, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 299-1401
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:14CENSUS: 11DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mitchell TarverTIME COMPLETED:
03:30 PM
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On 06/06/2023 at 12:30pm Licensing Program Analyst (LPA) Christina Uribe, met with licensee Mitchell Tarver for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 11 daycare children, 2 fingerprint cleared assistants (Rachel Wardrobe & Juanita Nunes), and 1 resident (Mary Miles) of home, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 8:00am-5:00pm.

The home is a two story home with 4 bedrooms, 2 bathrooms, living room, kitchen, dining area, downstairs living space (cubby room & main day care room), converted garage used for day care and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports.

The OFF-LIMIT AREAS is the entire second story of the home and are inaccessible to children by locked doors, safety gates and visual supervision. There is a safety gate in use at the bottom of the staircase.

The ON-LIMIT AREAS are the downstairs rooms, downstairs bathroom, converted garage, and backyard.

The facility’s outdoor play space is located in the backyard of the home. The play structure, equipment, and fence are all in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are locked at all times while children are in the yard. There are no pools, hot tubs or any other bodies of water present at the time of the inspection.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. Per licensee, there are no firearms on the premises and there is one pet dog which remains in the off-limit areas of the home.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MILES, MARY & TARVER, MITCHELL
FACILITY NUMBER: 010211221
VISIT DATE: 06/06/2023
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 11/11/2024. The licensee is in compliance with the immunization laws. Mandated reporter certificates were reviewed and are in need of being renewed as they have recently expired.

The licensee conducts and documents fire and disaster drills at least twice a year. All required forms are posted and visible for public review.

LPA Uribe reviewed 5 children’s files, personnel records, and Facility Roster (LIC 9040). The facility does have liability insurance which is valid through 11/07/2023. Licensee interview also conducted and documented.



Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders, by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.

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 inspectionprocess@dss.ca.gov. 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.

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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MILES, MARY & TARVER, MITCHELL
FACILITY NUMBER: 010211221
VISIT DATE: 06/06/2023
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Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

No deficiencies found during today's inspection. Please see attached pages and list below for advisory notes issued today:

  • Technical Violation: 15-minute checks on sleeping infants (aged 24 months or younger) must have documentation along with the physical check.
  • Technical Violation: Facility needs to either update their medical treatment authorization form or use the Consent for Emergency Medical Treatment (LIC 627) form.
  • Technical Violation: The licensee and assistants are in need of updating their Mandated Reporter Certificates for Child Care Providers (AB 1207) on www.mandatedreporterca.com
  • Technical Violation: Facility Roster (LIC 9040) is in need of being updated.

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

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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