013421573-11-15-2023-02-CC-CACA-CXLV3B-20231115150429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421573
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:04:42 PM

Document Has Been Signed on 11/15/2023 03:04 PM - 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	ELLINGBERG, KATRINA		FACILITY NUMBER:	013421573
ADMINISTRATOR:	ELLINGBERG, KATRINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 567-3337
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94605
CAPACITY:	14	CENSUS: 8	DATE:	11/15/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Katrina Ellingberg		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced 3 year required inspection. Present during today’s inspection was the licensee, her fingerprint cleared adult children/assistants, 6 preschool aged children and 2 infants in care. The home was toured for Health and Safety Inspection. During the previous inspection on 11/26/19, the on limits area was identified as the dining room/day care room, first floor bathroom, and kitchen. In addition to previously identified on limits areas, licensee was using the living room and the first floor bedroom for child care today. Licensee requested to add these areas as on limits for children in care. During the inspection these areas were observed to be safe for children and are approved to be used for child care. Licensee agrees to submit an updated facility sketch to Community Care Licensing by 11/30/23. The garage and the entire second floor remain off limits to children in care. Off limits areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. There are no pools, spas, hot tubs, or any other similar bodies of water at this home. There are no firearms on the premises as stated by the licensee. Detergents, cleaning compounds, medications and other items which could pose a danger to children are stored and inaccessible to children. Stairs are gated. LPA verified that the fire extinguisher 3A40BC is fully charged. The home is equipped with both a smoke detector and carbon monoxide detector. There is a working telephone in the home. The home provides appropriate toys, learning materials and play equipment. Outdoor play area is fenced. Licensee has two swing sets in the backyard that must be anchored to the ground for children's safety. Licensee agrees to make the swing sets off limits to children until the swing sets are anchored to the ground. Licensee agrees to have the swing sets anchored by 11/30/23.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ELLINGBERG, KATRINA	FACILITY NUMBER: 013421573
	VISIT DATE: 11/15/2023

NARRATIVE

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The licensee is operating within the licensed capacity. LPA did not observe any child left without supervision during the inspection.

Children’s files were reviewed. Licensee completed mandated reporter training 4/16/22. Licensee is in compliance with required immunizations for childcare providers.
Fire and disaster drills are conducted at least once every six months.

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-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

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

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

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ELLINGBERG, KATRINA	FACILITY NUMBER: 013421573
	VISIT DATE: 11/15/2023

NARRATIVE

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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/

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 platform.
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.

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

Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See 809-D for deficiency cited today.

A notice of site visit was provided and must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Katrina Ellingberg.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2023 03:04 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.3(a)(6)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During today's inspection licensee was using area identified as off limits for child care which poses a potential risk to the health and safety of children in care
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee shall submit an updated facility sketch. The sketch shall identify all areas of the home as either on limits or off limits. Licensee shall also submit a letter to CCL stating that she understands that she must notify CCL prior to making changes to the on/off limits areas of the home.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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