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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419028
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:05:44 PM


Document Has Been Signed on 07/27/2022 03:05 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:EVANS, CAROLFACILITY NUMBER:
013419028
ADMINISTRATOR:EVANS, CAROLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 600-0108
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:14CENSUS: 10DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Carol EvansTIME COMPLETED:
03:30 PM
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On July 27, 2022 Licensing Program Analyst, (LPA) Lorraine Dacanay Breaux made an unannounced 1 year required inspection to the facility. Met with Licensee, Carol Evans who was present with her husband, mother, and father all finger print cleared. Licensee was in ratio 10 children in care during the inspection. Hours of Operation are Monday - Saturday. 7: 00 AM-6:00 PM (recently started Saturday's)

This is a two story home. On Limit Areas: Family room, dining room, first floor bathroom, kitchen, living room, and backyard. OFF Limit Areas: Garage, entire second floor upstairs which includes master bedroom and bathroom and deck, two bedrooms and two bathrooms. Isolation area: Living room away from the children in care.

The facility had a working smoke detector, carbon monoxide detector, and fully recharged size 3A40BC fire extinguisher. There are no bodies of water such as pools, hot tubs, or similar bodies. Poisons, detergents, cleaning compounds, and medication were inaccessible to children. The fireplace has been blocked off with a child's play kitchen set. The home is kept clean and orderly, with heating and ventilation for safety and comfort. A child safety gate was in place at the stairway.

The home has safe toys, play equipment, and materials. The Licensee is present in the home and ensures that children are supervised at all times. Licensee was reminded that children are not to be left alone in vehicles. The Licensee maintains the capacity on the license. Each child has safe, comfortable, and healthful accommodations, furnishings, and equipment. Licensee stated there were no guns or weapons in the home. Children's files were reviewed and found to be complete including immunization requirements. The Licensee is conducting and documenting fire drills, infant sleep log in being maintained and utilizing the child care roster.

809-C
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 07/27/2022
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LPA discussed the safe sleep regulations with facility representative 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 facility representative 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.

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.

Licensee [or facility representative] 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.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee has current CPR/First Aid which expires 11/1/22.

California Law requires Child Care Homes 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.
809-C
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 07/27/2022
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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/process.

A notice of site visit was given and must remain posted for 30 days. Appeal rights provided. Exit interview conducted and report was reviewed with the licensee Carol Evans.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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