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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416337
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:50:43 PM


Document Has Been Signed on 08/04/2022 12:50 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:PIERCE, FORRESTINEFACILITY NUMBER:
013416337
ADMINISTRATOR:PIERCE, FORRESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-1109
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 10DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Forrestine Pierce- LicenseeTIME COMPLETED:
01:00 PM
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On 08/4/22 at 11:21am, Licensing Program Analyst Briana Plumboy, met with licensee Forrestine Pierce for an UNANNOUNCED REQUIRED 1 YEAR ANNUAL INSPECTION as well as for the purpose of removing licensee from required inspections. The licensee was placed on required inspections on 7/21/21 for a self reported incident, and has remained in compliance. Present for this visit was 4 infants, 6 preschool age children, and fingerprint clear assistants Ashley and Emilie Sarmiento. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 6:30am until 5:30pm.

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 living room, the kitchen, the dining room, the downstairs den, and the downstairs bathroom. The OFF LIMIT AREAS are the bedroom on the left located next to the bathroom, the upstairs hallway bathroom, first bedroom on the right, the first bedroom on the left, and the garage which will be inaccessible by closed and/or locked doors and visual supervision. The upstairs on limit areas are designed for infants, and the on limit areas located inside the lower level of the home are designed for toddlers. There is a door located inside the kitchen area which leads to the downstairs toddler area, as well as a gate located at the top of the stairs and a gate located at the bottom of the stairs. The ISOLATION AREA will be the dining room area located in the kitchen. The BACKYARD play area is fenced. There are toys, learning materials, and play equipment. 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 during today's inspection.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensees CPR and First Aid certificate is current and expires 1/15/24. The fireplace is screened and also has a barricade to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills at least twice a year with the last one conducted on 06/30/22. The licensee and her assistants present today all have received certificates in mandated reporter training. Both licensee and her assistants present are in compliance with the immunization law which pertains to providers. The licensee is in ratio today. The licensee documents infant sleep checks and utilizes Lic. 9227. All REQUIRED forms are posted and visible for public review. See 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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: PIERCE, FORRESTINE
FACILITY NUMBER: 013416337
VISIT DATE: 08/04/2022
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Incidental Medical Services (IMS) policy was discussed. 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

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Licensee is reminded that ALL assistants, volunteers, and staff, 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



LPA discussed the safe sleep regulations with licensee Forrestine Pierce 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 Forrestine Pierce 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.

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

No deficiencies cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Forrestine Pierce.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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