010215269-6-20-2022-52-CC-EWOS-CFKPM6-20220620112545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010215269
Report Date: 06/09/2022
Date Signed: 06/20/2022 11:26:08 AM

Document Has Been Signed on 06/20/2022 11:26 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	O'BRIEN, SUSAN		FACILITY NUMBER:	010215269
ADMINISTRATOR:	O'BRIEN, SUSAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 581-4727
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	14	CENSUS: 5	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Susan O'Brien		TIME COMPLETED:	03:45 PM

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 June 9, 2022, at 2:00 PM., Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual Required Inspection and met with licensee, Susan O'Brien. Present during the inspection were two (2) school age children and one (1) preschool age child. 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 LPA toured the facility to conduct a Health and Safety inspection. This single story home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The Isolation area will be a section of the living room, away from other children in care. On-limit-areas are the: Living room, hallway bathroom, 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 There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. There are ample age appropriate toys that appear to be safe and in good condition. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, first aid kit, and telephone. 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 outdoor play area is the front yard and the licensee is reminded to have 100% visual supervision when outdoors since it's unfenced. 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. See 809-C for continuance

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika Woods	TELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: O'BRIEN, SUSAN	FACILITY NUMBER: 010215269
	VISIT DATE: 06/09/2022

NARRATIVE

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At 2:30 PM LPA requested and reviewed the files of two (2) children in care. All children files contain Immunization, Parent's Rights, and Medical Consent forms. The facility roster was reviewed, and copies were obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 3/17/22. The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 4/15/24. The licensee has completed mandated reporter training on 06/22/21. The licensee is in ratio today. All required forms are posted and visible for public review.

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. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

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

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 CPR/First Aid is renewed every two years. Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

The licensee is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

See 809-C

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika Woods	TELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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: 06/09/2022

NARRATIVE

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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.

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.

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/inspection-process.

There are no deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Susan O'Brien.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika Woods	TELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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