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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010215269
Report Date: 06/15/2021
Date Signed: 06/15/2021 03:47:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:O'BRIEN, SUSANFACILITY NUMBER:
010215269
ADMINISTRATOR:O'BRIEN, SUSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-4727
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 2DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Susan O'BrienTIME COMPLETED:
04:15 PM
NARRATIVE
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On June 15, 2021, at 2:15 PM., Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual Required Inspection and met with licensee, Susan O'Brien. Present during the inspection was licensee's fingerprint cleared husband Gary O'Brien. There were two (2) school age children present. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. The facility plans to operate between the hours of 7:00 AM-6:00 PM, Monday -Friday

On-limit-areas are the: Living room, dining room, kitchen, play room, bathroom next to the playroom, and laundry room

Off-limit-areas are : Entire back yard area which is inaccessible by a gate, closed and/or locked doors and visual supervision

This home is a single-story home consist of 3 bedrooms, 1 and a half baths, living and dining room, kitchen,, playroom and backyard, which is neat and clean with heating and ventilation for safety and comfort. The off-limits will be made inaccessible by closed and/or locked doors and visual supervision. The Isolation area will be a section of the living room, away from other children in care. The outdoor play area is the front yard and the licensee is reminded to have 100% visual supervision when outdoors since it's unfenced.

There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection.

See 809-Continuation
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: O'BRIEN, SUSAN
FACILITY NUMBER: 010215269
VISIT DATE: 06/15/2021
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The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and telephone. The licensee's CPR & first aid is current and expires 12/4/2021. The licensee is in the process of completing a certificate in mandated reporter training. All required forms are posted and visible for public review.

The fireplace is blocked to prevent access by children and there are no heaters accessible to children in care.

Per licensee, there are firearms in the home. LPA verified that the firearms are stored properly. The licensee is in compliance with the immunization laws which pertains to all childcare providers. All required forms are posted and visible for public review.

At 3:00 PM LPA requested and reviewed the files of two (2) children in care. The facility roster was reviewed, and copies was obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 05/19/21. The licensee is in ratio today.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of her responsibility as mandated reporter.

California Law requires Family Child Care Home 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

See Continuation

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: O'BRIEN, SUSAN
FACILITY NUMBER: 010215269
VISIT DATE: 06/15/2021
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LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

Roster of the children must be properly maintained and fire/disaster drill every six months must be documented. The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370).



Incidental Medical Services (IMS) policy was discussed. Per licensee, no IMS is being provided at this time. The licensee was reminded that when any changes to the IMS plan is made, an updated 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.”

There are no deficiencies cited. This report shall remain on file for 3 years. Exit interview was conducted with the licensee. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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