013415925-9-16-2019-52-CC-BPLY-BG3MXN-20190916100013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013415925
Report Date: 09/16/2019
Date Signed: 09/16/2019 10:00:20 AM

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:	KOTSAKIS, KALLIOPI		FACILITY NUMBER:	013415925
ADMINISTRATOR:	KOTSAKIS, KALLIOPI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 471-2628
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	14	CENSUS: 7	DATE:	09/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Kalliopi Kotsakis		TIME COMPLETED:	10:10 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	On 09/16/19, Licensing Program Analyst Briana Plumboy, met with licensee Kalliopi Kotsakis for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was licensees fingerprint clear husband N. Kotsakis, 4 infants, and 3 preschool age children. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:00am until 6:00pm. The home is a two story home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the front rooms, living rooms, bathroom, and kitchen. The OFF LIMIT AREAS are the entire second level of the home, the master bedroom, the backyard, and the garage which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be the front room located all the way to the left. The FRONT YARD PLAY AREA is fenced. There are ample age appropriate toys and learning materials. There are no pools, hot tubs or any other bodies of water present in the on limit areas during today's inspection. 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 to children in care during today's inspection. The licensee has a gate at the bottom of her stairs to prevent access to the second level of the home. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee CPR and First Aid certificate is current and expires 03/10/20. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee received a certificate in mandated reporter training on 10/15/18. The licensee and her husband have the required provider immunization's. The licensee documented her last fire/disaster drill on 03/15/19. Children's files contain all required licensing documents. All REQUIRED forms are posted and visible for public review. See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2019

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: KOTSAKIS, KALLIOPI	FACILITY NUMBER: 013415925
	VISIT DATE: 09/16/2019

NARRATIVE

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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 Plumboy 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

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.

Effective August 1, 2003 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.

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

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) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2019

LIC809 (FAS) - (06/04)

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