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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417598
Report Date: 07/21/2022
Date Signed: 07/21/2022 12:51:46 PM


Document Has Been Signed on 07/21/2022 12:51 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CUSTER, ANTOINETTEFACILITY NUMBER:
013417598
ADMINISTRATOR:CUSTER, ANTOINETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 658-2505
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY:14CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Antoinette CusterTIME COMPLETED:
01:00 PM
NARRATIVE
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On 07/21/2022 Licensing Program Analyst (LPA) Arminder Singh met with Licensee, Antoinette Custer and explained the purpose of today's visit. Present during inspection was Licensee's fingerprint cleared Assistant. There are 6 children present today. LPA reviewed 3 children's file during todays' visit. All children's files reviewed contained the Licensing forms that are required per CCLD regulations. The home was toured to conduct a health and safety inspection. The Licensee's hours of operation are Monday-Friday, 6:00AM-6:00PM. Licensee has a working telephone in the home.

The home is a two story home with an attached garage. The home has four bedrooms, three bathrooms, children's room (located on first floor), living room, kitchen, dining room, laundry room, den, fenced front yard, fenced back yard, and garage.

On Limit AREAS: The entire first floor is on limits to the children.
OFF LIMIT AREAS: The second floor is off limits,back yard, and garage.

Licensee states there are no firearms in the home. Licensee does have a pet fish in the home. The children's room is the isolation room if needed. Licensee understands that while child is in isolation room there should be 100% visual supervision at all times. Licensee does have a fully stocked first aid kid.

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SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CUSTER, ANTOINETTE
FACILITY NUMBER: 013417598
VISIT DATE: 07/21/2022
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The home is sanitary, safe and orderly, with central heating and ventilation for safety and comfort. LPA observed required Postings on the wall. LPA observed: fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector. There is a fireplace in living room that is properly barricaded and made inaccessible to the children. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and out of reach of children. LPA reminded Licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes.

The Licensee has enrolled in CPR and First Aid classes. LPA reminded Licensee that the mandated reporter training certificates are to be renewed every two years. Licensee has current mandated reporter training certificates and is valid until 02/03/2024. Licensee conducts fire/disaster drills and last one was conducted on 04/2022.

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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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: CUSTER, ANTOINETTE
FACILITY NUMBER: 013417598
VISIT DATE: 07/21/2022
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensees 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.

There were no deficiencies in today's visit.

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

Exit interview was conducted and report was reviewed with the Licensee, Antoinette Custer.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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