013411075-8-16-2022-52-CC-SCOZ-CHCS6S-20220816133625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013411075
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:36:45 PM

Document Has Been Signed on 08/16/2022 01:36 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
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: 3	DATE:	08/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	MISTI SHORT		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst Sidney Cortez, met with licensee Misti Short for an UNANNOUNCED ANNUAL RANDOM INSPECTION. Present for this visit was the licensee Misti Short. Present on this visit 2 Preschool age children, 1 school age. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:00AM until 6PM, MONDAY-FRIDAY.

The home is one story which consists of 5 bedrooms, 2 bathrooms, living room, day care room, kitchen, dining area, detached garage, and front yard. The home is clean with heating and ventilation for safety and comfort.

the On Limits areas. The OFF LIMIT AREAS are all the bedrooms, master bathroom, and garage which will be inaccessible by closed and/or locked doors and visual supervision at all times.

ISOLATION AREA will be the den area (right side of the house). There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. Per licensee, there are no firearms in the home.

The home has a working smoke detector, carbon monoxide detector, working telephone, and First Aid Kit.

The home has a fully charged (3A40BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone. The licensee CPR and First Aid certificate is current and expires (May 2023). The licensee's mandated reporter training is up to date; and will expire at August 2023 and is valid for 2 years. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on June 2022. 2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney Cortez	TELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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: SHORT, MISTI & BRIAN	FACILITY NUMBER: 013411075
	VISIT DATE: 08/16/2022

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LPA Cortez provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee. LPA Cortez provided licensee with a copy of the CDSS handout on Effects of Lead Exposure and Never Shake a Baby Brochure (attached PUB 271). The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice. 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 624). 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.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.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 the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list. This entire report has been read to the Licensee by LPA Cortez. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Cortez or CCLD.

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney Cortez	TELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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