013411778-9-1-2023-02-CC-ACUY-CV9NG9-20230901102646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013411778
Report Date: 09/01/2023
Date Signed: 09/01/2023 10:26:56 AM

Document Has Been Signed on 09/01/2023 10:26 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	HANCOCK, DORIS Y.		FACILITY NUMBER:	013411778
ADMINISTRATOR:	DORIS Y. HANCOCK		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 654-9077
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	12	CENSUS: 1	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Doris Hancock		TIME COMPLETED:	12:00 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 9/1/2023 at 9:00 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced random inspection. LPA met with licensee, Doris Hancock, who granted inspection authority to tour the facility. Also present for the inspection was 1 infant. Licensee states there are currently 12 children enrolled. Children’s files were reviewed. The children use the bathroom in the hallway, living room, kitchen, and dining area. The off-limit areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is in the kitchen away from other children. The LPA toured all areas used by children. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were no fireplaces or open face heaters accessible to children. There were safe toys, play equipment, and materials observed for children. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke alarm, and working carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee indicated she did not have a current CPR and First Aid training certificate (See 809). LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that cribs and/or play yards were free from loose articles and objects. There are no objects hanging above or attached to the side of the crib. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was also advised that all infants of to 12 months of age shall have the LIC 9227 form placed in their file. The LIC 9227 form was provided during today's visit. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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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Document Has Been Signed on 09/01/2023 10:26 AM - It Cannot Be Edited

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HANCOCK, DORIS Y.	FACILITY NUMBER: 013411778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by ensuring she has a valid CPR/First Aid Card, which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee indicated her CPR/First Aid card is expired.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	By 09/29/2023 send proof of completion of a EMSA certified CPR/First Aid course or proof of enrollment into course.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HANCOCK, DORIS Y.	FACILITY NUMBER: 013411778
	VISIT DATE: 09/01/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

During the exit interview, the licensee Doris Hancock, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Doris Hancock.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley Curry	TELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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