013420371-12-19-2019-02-CC-SNEN-BJZVRZ-20191219154047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420371
Report Date: 12/19/2019
Date Signed: 12/19/2019 03:40:56 PM

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:	GARDNER, KATHLEEN		FACILITY NUMBER:	013420371
ADMINISTRATOR:	GARDNER, KATHLEEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 333-5570
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	14	CENSUS: 3	DATE:	12/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Kathleen Gardner		TIME COMPLETED:	04:00 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	An unannounced Annual/Random site inspection visit was conducted by LPA Susan Neeson. Met with Kathleen Gardner. She stated that she resides here with a roommate. Both adults are fingerprint clear. Visit began at 2:20 PM. There are three children present. One is an infant and the others are preschoolers. The home was toured to conduct a health and safety inspection. The home is one story. The entire home was inspected. The home consists of a living room, kitchen, dinning room, 3 bedrooms, 2 bathrooms, Day care is done in living/dining area and one bedroom. The bathroom in the hall is used for children. Two bedrooms and one bath are off limits. Children play in the side and back yard which are fenced and contain safe toys and equipment for children. The home has a 3A10BC fire extinguisher, a working smoke alarm, and carbon monoxide detector. There is no fireplace. The home has central heat.. The home is clean and orderly. There are adequate toys and equipment for children in care. All poisons, detergents, cleaning compounds and medications are stored in areas which are inaccessible to children. All required forms are posted. Last fire drill was conducted 10/10/19. Ms. Gardner takes the children to the neighborhood park for outdoor play at times. Records were reviewed. CPR and first aid are current to 8/20. The family has no pets. Kathleen Gardner states that there are no guns or firearms in the home or garage. Licensee is reminded that ALL assistants, volunteers or adults 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 and for day care updates visit www.myccl.ca.gov.

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan Neeson	TELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

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: GARDNER, KATHLEEN	FACILITY NUMBER: 013420371
	VISIT DATE: 12/19/2019

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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. No child currently enrolled needs IMS.

The following documents were issued and discussed: blue immunization forms, Flu prevention information, Quarterly update from Department, AB 1207 information, Safe Sleep for infants, Fire/earthquake drill information, Parents Rights and Licensee rights. .

Copy of roster is requested. Copy of LIC 500 is requested.

No deficiencies are observed.

An exit interview was given.

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan Neeson	TELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

LIC809 (FAS) - (06/04)

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