013419122-12-6-2022-52-CC-SCOZ-CLUTVT-20221206140428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013419122
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:04:53 PM

Document Has Been Signed on 12/06/2022 02:04 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:	YOUNG, KATINA		FACILITY NUMBER:	013419122
ADMINISTRATOR:	YOUNG, KATINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 881-9841
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	14	CENSUS: 4	DATE:	12/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Katina Young		TIME COMPLETED:	03:36 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	Licensing Program Analyst Sidney Cortez, met with licensee Katina Young for an UNANNOUNCED ANNUAL RANDOM INSPECTION. Present for this visit was the licensee Katina Young, her fingerprint cleared assistant Undrea Ward, and 4 pre school age children. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 6:30AM until 6PM, MONDAY-FRIDAY.The facility is a one (1) story, residential home. The facility consists of a multi-purpose/classroom, living, family room and kitchen areas with bedrooms, bathrooms, garage, and a yard. Overall the facility appears clean and in good repair. There are adequate and age appropriate toys, furniture and equipment. The home has a working smoke detector, carbon monoxide detector, working telephone, and First Aid Kit.. "ON LIMIT": Multi-purpose room, classroom (located outside of kitchen area), Living Room, Bedroom, which includes a sleeping area and activity room. Restroom: toilet and faucets are in working order, there is toilet paper and paper towels. Kitchen: There are no accessible sharp items, cleaning solutions, or other hazardous items. Outdoor play area (not currently used due to weather): is fenced. Off limits are: Master bedroom, the room located in between the master bedroom and kitchen dining area. The ISOLATION AREA will be the living room. There is a covered and properly locked jacuzzi on the off limit area of the backyard.. All hazardous materials and toxins are kept out of the reach of children. Per licensee, there are no firearms in the home. The home has a fully charged (3A40BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone. The licensee CPR and First Aid certificate is current and expires (Oct , 2024). The licensee's mandated reporter training is current and will expire in Jan 2024. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on Nov 2022. 2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809 C for Continuation

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney Cortez	TELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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 2

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: YOUNG, KATINA	FACILITY NUMBER: 013419122
	VISIT DATE: 12/06/2022

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

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.

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 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.
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

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) 622-2602
LICENSING EVALUATOR NAME: Sidney Cortez	TELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2