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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421573
Report Date: 11/26/2019
Date Signed: 11/26/2019 10:25:43 AM

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:ELLINGBERG, KATRINAFACILITY NUMBER:
013421573
ADMINISTRATOR:ELLINGBERG, KATRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 567-3337
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:14CENSUS: 5DATE:
11/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Katrina EllingbergTIME COMPLETED:
10:33 AM
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An unannounced Annual/Random inspection was conducted by LPA Dyer. The licensee was present with 5 day care children (5 preschoolers). Licensee was in compliance with her licensed capacity and facility ratios. Hours: 7:30 am - 5:30 pm. The home was inspected. Areas licensed for child care: day care room; bathroom, and kitchen. Off-limit areas will be made inaccessible to children by closed and/or locked doors; gates; and visual supervision.

All required forms are posted and visible for public review. There was a working smoke detector (tested); a fully charged 3-A:40-B:C fire extinguisher; a first aid kit, and a carbon monoxide detector. The home was clean and orderly. There were safe, healthful and comfortable accommodations, furnishings and equipment available to children at the time of this inspection. There was no fireplace. There are no hazardous materials, medicines, or cleaning solutions accessible to children during this inspection. Hazardous items are kept locked under the kitchen sink, inaccessible to children. Stairs are gated. Licensee stated there were no firearms or bodies of water on the premises. Two children's files were reviewed at 9:03 am. Licensee is conducting and documenting fire drills and utilizing the child care roster. Phone number is current.

Back yard area is securely fenced. There is riding toys, slides, a basketball hoop, playhouse, bikes and other toys for outside play. LPA pointed out an area in the backyard where additional care should be taken to watch children.



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. (continued)
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ELLINGBERG, KATRINA
FACILITY NUMBER: 013421573
VISIT DATE: 11/26/2019
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All adults meet criminal background clearance requirements. Licensee's Pediatric First aid and CPR cards expire 1/05/21. Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. A qualified assistant must be physically present whenever 9 or more children are in care. When an assistant is not present, the home reverts back to small family child care ratios.

Licensee was aware of the New Regulations regarding Adult Immunizations and Mandated Reporter Training. Licensee has immunizations in file, and a current Mandated Reporter Training certificate that expires 3/30/20.

Licensee was also reminded of the Department's Inspection authority, and the need to comply when notified that termination of an employee is necessary. The handout, "A Child Care Provider's Guide to Safe Sleep" was provided at the last inspection and discussed again today. Also discussed with the licensee: children in parked vehicles; substitutes; fingerprinting/association; advertisements; changes in on-limit areas; paying fees on-line and smoking. Licensee was encouraged to frequently visit the licensing website at www.ccld.ca.govfor licensing regulations, forms and updates.

For CCL Updates, go to www.ccld.ca.gov. Click the "Receive Important Updates" box. Enter your e-mail address.

For a free Indoor Radon Gas Test Kit for your facility, email: radonprogram@cdph.ca.gov or call 1-800-745-7236.

There are no deficiencies cited today.

Notice of site visit must be posted for 30 days. An exit interview was conducted. This report must be available for public review for 3 years
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
LIC809 (FAS) - (06/04)
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