013420722-1-17-2023-52-CC-MPRE-CN6QU3-20230117112805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420722
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:28:17 AM

Document Has Been Signed on 01/17/2023 11:28 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
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:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Sydney Smith		TIME COMPLETED:	11:25 AM

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On 1/17/2023 at 10:07am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Sydney Smith for an Unannounced Annual Inspection. Present during the inspection was the Licensee, and four (4) preschool age children, two (2) infants, one (1) unrelated thirteen-year-old child who was helping for the day and Licensee's seventenn (17) year old son. Licensee lives in the home with her fingerprint cleared husband J. Smith, their seventeen (17) year old son and their eleven (11) year old daughter. Licensee home was toured for a health and safety inspection. The facility operates am 5:30am– 5:30pm, Monday - Friday.

ON LIMITS AREA: Living Room, Dining Area, Kitchen, Bedroom 1 , Bedroom 3 (Master Bedroom) with attached Bathroom, Hallway Bathroom and Backyard

OFF LIMITS AREA: Bedroom 2 and Garage
ISOLATION AREA: Bedroom 1

The facility is a single-story home owned by the Licensee. The inside of the home was observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee provides all food for the children that is properly stored and maintained. All food that may be brought from the children’s home will be properly labeled and stored. Licensee stated that there is one (1) firearm and two (2) dogs in the home.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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: 01/17/2023

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The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen. There is one (1) working smoke/carbon monoxide detector in the living room, the hallway and every bedroom. The home is equipped with a horizontal wall heater/air conditioner in the kitchen that has been installed right below the ceiling, making it inaccessible to the children in care. The electric fireplace in the living room is not in use and does not open making it no danger to the children in care. The backyard is fully fenced and clean with ample age appropriate materials for the children. There is a jacuzzi on the left side of the home in the back yard. The jacuzzi has been gated, emptied and locked, making it no harm to the children in care. There is also a trampoline. Both the trampoline and jacuzzi is gated off on the left side of the home making them inaccessible to the children in care.

The Licensee’s Health and Safety training has been completed and CPR and First Aid training is complete with an expiration date of 1/14/2025. Licensee’s Mandated Reporter training is complete and expires on 1/8/2025. LPA obtained the fire/disaster drill log. Log is complete with the last drill completed today, 1/3/2023. All required forms are posted and visible for public view by the front door. Licensee stated that she does transport children. LPA obtained vehicle documentation and observed proper car seats for transportation. LPA obtained the children’s files and the facility roster. All files were complete.

Licensee was reminded that California Law requires Licensee 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 email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care

Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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: 01/17/2023

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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 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.

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.

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.

Exit interview conducted and report was reviewed with Licensee Sydney Smith.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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