013420722-4-26-2024-52-CC-MPRE-D4PPYJ-20240426114401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420722
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:44:09 AM

Document Has Been Signed on 04/26/2024 11:44 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:	04/26/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Sydney Smith		TIME COMPLETED:	11:43 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 4/26/2024 at 9:04am Licensing Program Analysts (LPAs) Morgan Pringle and Jialing (Julianne) Zhu met with Licensee Sydney Smith for an Annual/Random Inspection. Present during the inspection was the Licensee, her husband, two (2) infants and four (4) preschool age children. Licensee’s husband was in the home in an off-limit area when LPAs arrived and left around 9:30am. Licensee lives in the home with her husband, adult son and minor daughter. The facility operates from 5:30am – 5:30pm, Monday – Friday. ON LIMITS AREA: Living Room, Dining Area, Kitchen, Bedroom 1, Hallway Bathroom and Backyard OFF LIMITS AREA: Master Bedroom and Bathroom, Bedroom 2 and Garage ISOLATION AREA: Bedroom 1 The facility is a single-story home owned by the Licensee. The inside of the home is 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 stated they provide all food for the children which was observed to be properly maintained and stored. All food that may be brought from the children’s home will be properly labeled and stored. All bedding was clean and properly stored. All off limit areas are made inaccessible with closed doors, locks, and gates. LPAs observed a hallway closet with vitamins, LPAs informed Licensee that although the vitamins are placed on the top shelf it would be best to lock the closet to make it completely inaccessible to the children in care. Licensee stated she does transport children when needed and walks with the children to the nearby elementary school for school pickups. Licensee stated there are two (2) firearms in the home and three (3) dogs in the home. Page 1 of 4

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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: 04/26/2024

NARRATIVE

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There is one (1) fully charged 3A40BC fire extinguisher on wall by the sliding glass door leading to the backyard. There is one (1) working smoke/carbon detector in the hallway. 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 accumulated a small amount of rainwater. LPAs instructed the Licensee to empty the jacuzzi and relock it. There is also a trampoline next to the jacuzzi. Both the trampoline and jacuzzi are gated off on the left side of the home making them inaccessible to the children in care.

The facility is operating within its licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and EMSA approved Pediatric CPR & First Aid has been complete and expires 1/14/2025. Licensee’s Mandated Reporter training is complete and expires 1/8/2025. Fire/disaster drills have been conducted and recorded with the last drill logged 10/18/2023. LPAs informed Licensee that a fire/disaster drill will need to be conducted by the end of the month to be in compliance with the 6-month requirement. Proof of completion will be sent to LPA Pringle. All required forms are posted and visible for public view on the walls in the living room. LPAs obtained a sample of the children’s files, and facility files. All files were complete.

No deficiencies were cited during LPAs inspection.

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented.

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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: 04/26/2024

NARRATIVE

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Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee Sydney Smith, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 04/26/2024

NARRATIVE

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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.

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 information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

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

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC809 (FAS) - (06/04)

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