013420722-5-15-2019-52-CC-LDYN-BC7TKJ-20190515144802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420722
Report Date: 05/15/2019
Date Signed: 05/15/2019 02:48:10 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SMITH, SYDNEY		FACILITY NUMBER:	013420722
ADMINISTRATOR:	SMITH, SYDNEY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 200-9486
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	14	CENSUS: 6	DATE:	05/15/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Sydney Smith		TIME COMPLETED:	03:00 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	On 5/15/19 at 1:39pm, Licensing Program Analyst (LPA) Loretta Dyson arrived at the home for an unannounced random inspection. LPA met with the licensee. There was 1 infant and 5 preschool age children present. At 1:45pm, LPA requested and reviewed the licensee's CPR and first aid certificates, which expire on 1/31/21. LPA reviewed the facility roster and obtained a copy. LPA reviewed the files of 2 children in care. The licensee conducts and documents fire and earthquake drills and the log indicates that drills were conducted on 3/13/19. The licensee has completed the required mandated reporter training, and LPA reviewed the certificate which is dated 3/25/18. At 1:58pm, LPA toured the areas of the home used for the child care, to conduct a health and safety inspection. The home is a single story home, which is neat and clean with heating and ventilation for the safety and comfort of children in care. The on limit areas include the living room, dining area, kitchen, first bedroom on the right side of the hallway, hallway bathroom, and bedroom at the end of the hallway and the bathroom in this bedroom. The off limit areas include the second bedroom on the right side of the hallway and the garage, which are made inaccessible by closed and/or locked doors and visual supervision. The isolation area will be a section of the living room, away from other children in care. The fenced backyard is used for the outdoor play area. The backyard is separated into sections by gates. The section of the yard to the right side of the home is off limits, and includes a hot tub which is locked to prevent access by children. The section to the left side of the yard is off limits. The section of the yard used for children is free from defects or dangerous conditions. LPA did not observe any bodies of water, hazardous items or toxins accessible to children today. LPA observed an ample supply of toys and activities, which are age appropriate and appear to be in good condition. All of the required forms are posted and visible for public review. The home has a fully charged 3A40BC fire extinguisher, working combination smoke/carbon monoxide detector, telephone and first aid supplies. There are no heaters accessible to children. There is an electronic fireplace, and it was not hot to the touch when LPA checked it. LPA inspected the storage locations for the firearm and ammunition, and verified that they are stored separately, in a locked box in an off limit area of the home. continued on 809C

SUPERVISOR'S NAME: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SMITH, SYDNEY	FACILITY NUMBER: 013420722
	VISIT DATE: 05/15/2019

NARRATIVE

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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.

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. LPA reviewed the individuals associated to the license, and the licensee confirmed that everyone who is required to have a criminal record clearance is associated. Licensee was reminded of the responsibility as a mandated reporter.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to sign up to receive quarterly updates by email by sending a request to ChildCareAdvocatesProgram@dss.ca.gov. The Licensee was given a copy of A Child Care Provider's Guide to Safe Sleep pamphlet and LPA discussed safe sleep practices and policy.

There are no deficiencies being cited today. This report shall remain on file for 3 years. A Notice of Site visit was given to Licensee, and Licensee was reminded that it is required to be posted for 30 days. An exit interview was conducted with the licensee.

SUPERVISOR'S NAME: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019

LIC809 (FAS) - (06/04)

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