013411075-5-23-2019-52-CC-LCHW-BCFNDD-20190523102209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013411075
Report Date: 05/23/2019
Date Signed: 05/23/2019 10:22:41 AM

COMPREHENSIVE INSPECTION

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:	SHORT, MISTI & BRIAN		FACILITY NUMBER:	013411075
ADMINISTRATOR:	SHORT, MISTI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 276-5220
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	14	CENSUS:	DATE:	05/23/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:			TIME COMPLETED:	10:35 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	I, Licensing Program Analyst, Jason Jang and Lakeisha Chew made an annual random inspection to the facility that began at 7:30 am. We met with the Licensee, Misti and Brian who were present with two infants and four preschool children. The Licensee lives at the facility with her husband, daughter Katrina Short, two foster children, and granddaughter. All of the adults meet the criminal background clearance requirement. The areas used for the childcare are the entire facility consisting of a family room, dining room, office, kitchen, five bedrooms, two bathrooms, and front yard. The off limits areas are the garage and backyard. The facility had a working smoke detector, carbon monoxide detector and fully recharged size 2A10BC fire extinguisher. All bodies of water such as pools or hot tubs were inaccessible to children. The fire place is blocked off. The home is kept clean and orderly, with heating and ventilation for safety and comfort. The home has safe toys, play equipment, and materials. The Licensee is present in the home and ensures that children are supervised at all times. Licensee was reminded that children are not to be left alone in vehicles. When temporarily away, the Licensee arranges for a substitute adult to care for the children. The Licensee maintains the capacity on the license. Each child has safe, comfortable, and healthful accommodations, furnishings, and equipment. The Licensee had a current pediatric CPR and first aid certificate. Licensee stated there were no guns or weapons in the home. Licensee has two dogs. At 8:30 am, 4 children's file were reviewed and found to be complete..

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019

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: SHORT, MISTI & BRIAN	FACILITY NUMBER: 013411075
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/06/2019 Section Cited HSC 1596.8662	1 2 3 4 5 6 7	The Licensees have not completed the mandated reporter training as evidenced by a lack of proof. This poses a risk to the health and safety of children in care. www.mandatedreporterca.com	1 2 3 4 5 6 7	Licensee's shall complete the training by 7/6/19.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019

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: SHORT, MISTI & BRIAN	FACILITY NUMBER: 013411075
	VISIT DATE: 05/23/2019

NARRATIVE

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Licensee owns the facility. The Licensee is utilizing the child care roster. Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Also discussed: nutrition education; the new appeal process; and documents to be provided to parents/legal guardians. Upon notice of the Department to remove an individual from the home or to exclude an individual from the home, the Licensee immediately removes the individual and prevents them from returning to the home or having contact with children. 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 (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 Please register your email address at childcareadvocatesprogram@dss.ca.gov for all new licensing updates.

An exit interview was conducted with the Licensee. Appeal rights were given to the Licensee.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha Chew	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019

LIC809 (FAS) - (06/04)

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