<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419028
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:13:21 AM


Document Has Been Signed on 09/06/2023 11:13 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
OAKLAND SOUTH EAST, 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: 8DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Carol Evans TIME COMPLETED:
11:35 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 September 6, 2023 at approximately 09:15 AM, Licensing Program Analyst, (LPA) Lorraine Dacanay Breaux made an unannounced 1 year required inspection. LPA Dacanay Breaux met with Licensee,C. Evans present for the inspection was licensee's husband, mother, father, and daughter all finger print cleared eight. There were (8) children, 2 infants and 6 preschool age during todays inspection. Hours of Operation are Monday - Saturday 7: 00 AM - 6:00 PM.

This is a two story home. On Limit Areas: Family room, dining room, first floor bathroom, kitchen, living room, and backyard. OFF Limit Areas: One bedroom on the lower lever, entire second floor upstairs which includes master bedroom and bathroom/deck, two bedrooms and two bathrooms. Isolation area: Living room away from the children in care. There is a child gate at the bottom of the stairs preventing children from accessing the upstairs areas.

The facility was toured inside and outside for health and safety. The home has safe toys, play equipment, and materials. The facility had a working smoke detector, carbon monoxide detector (tested and functioning), and fully charged 3A40BC fire extinguisher located in the kitchen, working telephone and fully stocked first aide kit. 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. The outdoor play area is the rear yard and is fully fenced. There are no pools, hot tubs, or any other bodies of water present in the on-limit areas during today’s inspection. Per licensee there are no fire arms on the premises during todays visit. All hazardous materials and toxins are kept out of reach from children and are not accessible.

CPR/First Aid certification expires on 11/26/24. The licensee completed the mandated reporter training on 3/17/22. Licensee is reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years for all employees/volunteers working in the child care home. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 08/21/2023. All required forms are posted and visible for public review.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 09/06/2023
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
26
27
28
29
30
31
32
Records: At 10:10AM LPA Dacanay Breaux reviewed four (4) children’s files and personnel records. Individual Infant Safe Sleep Plans are complete and in child's file. Sleep Charts for sleeping infants were reviewed and within compliance of the Safe Sleep Regulations. There is a current roster available for review and copy obtained. The facility does have liability insurance and LPA reviewed expires on 06/14/2024.

Provider Information Notices (PINs) & Quarterly Updates: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders, by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.
CCLD Inspection Process: 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.

Criminal Record Clearance: 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.

Safe Sleep: 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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 09/06/2023
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
26
27
28
29
30
31
32
Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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/resources/child-care-centers/.

MyChildCarePlan.org: 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.

Megan’s Law: During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care 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 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

No deficiencies nor advisory notes issued during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. 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: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3