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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421935
Report Date: 05/12/2023
Date Signed: 05/12/2023 11:58:49 AM


Document Has Been Signed on 05/12/2023 11:58 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:WILSON, DANAFACILITY NUMBER:
013421935
ADMINISTRATOR:WILSON, DANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 321-1232
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 9DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dana WilsonTIME COMPLETED:
12:00 PM
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On May 12, 2023 at approximately 8:30am Licensing Program Analyst (LPA) Haderer arrived and met with the licensee Dana Wilson for the purpose of conducting an unannounced 1-year annual inspection for Health and Safety compliance. Present in the home today was the licensee, and 9 children in care (3 infants; 6 two-years old) and a parent volunteer (parent of a child in care). The facility is in ratio today. Hours of operation are Monday-Friday 8:00 to 6:00pm.

The facility is a single-story home with 3 bedrooms; 2 bathrooms; living room; family room (day care are); dining room; kitchen; attached 2-car garage; front, back and side yards. The home has heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in the on-limits living room away from the other children in care. All required postings are present.

ON LIMIT AREAS: Family room (day care area), house bathroom, patio area of the backyard, and side yard to enter from the street. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products.



OFF LIMIT AREAS: Living room, kitchen, all three bedrooms, and master bathroom, attached 2-car garage; north side of the back yard and side yard to the north and front yard. The off-limit areas will be inaccessible by child gates, closed and/or locked doors and adult supervision.

The home has a fully charged 2A10BC fire extinguisher located on the floor of the garage, combined smoke and carbon monoxide detector (tested and working) and a working telephone. There is a screened fireplace in the off limits living room. Fire drills are conducted at least once every 6 months, the last drill was completed December 13, 2022.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935
VISIT DATE: 05/12/2023
NARRATIVE
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Licensee has ample age-appropriate toys and learning materials inside and outside the home. The outdoor play area is free from defects and dangerous conditions. Per licensee, there are no firearms in the home. Drop-down cribs are not allowed at the day-care facility. Toxins, medicines, and hazardous items were inaccessible during today's inspection.
Children's files were reviewed. The facility roster was reviewed, and a copy obtained. Some children's files were missing various items including the following: Signed receipt of Parents Rights form LIC995; signed Consent for Emergency Medical Treatment form LIC627; Safe Sleep Plan for an infant LIC9227; Immunization Records missing; unsigned LIC282 Notice of no Liability Insurance. See LIC809D for deficiencies.
Licensee has a volunteer to assist in childcare, the volunteer is a parent of a child in care and therefore is exempt for a criminal record clearance. Licensee’s CPR/1st Aid expired November 3, 2022. Mandated Reporter expired on 5/05/2023 - See LIC809D for deficiencies. Licensee was reminded that CPR/1st Aide and Mandated Reporter is to be renewed every two years.

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.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935
VISIT DATE: 05/12/2023
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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/inspection-process.

The following seven deficiencies were observed during today's inspection:

· Licensee’s CPR/1st Aid certificate expired


· A storage shed in the on-limits patio area was unlocked

During review of children's files:
· Immunization records were missing
· Signed receipt of Parent’s Rights form not in file
· Signed Consent for Medical Treatment form not signed by parent
· No Infant Safe Sleep Plan in an infant’s file
· Signature acknowledging licensee has no insurance was not signed

See 809D for deficiencies cited today. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

**Please see LIC 9102 for Advisory Notes.

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



Exit interview conducted and report was reviewed with the licensee Dana Wilson.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/12/2023 11:58 AM - 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that a storage shed in the on limits backyard area was unlocked which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee immediately locked the storage shed clearing the deficiency this day. Going forward, licensee will ensure the shed is always kept locked at all times.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee's CPR/1st Aid certificate expired November 3, 2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee to enroll in a pediatric CPR/1st Aid course and submit updated certificates to LPA as proof of completion.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 05/12/2023 11:58 AM - 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that immunization records were not present for 3 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee to collect immunization records for the children's files. Going forward, licensee will ensure all children enrolled will include their immunization records.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that consent for Emergency Medical Treatment form LIC627 missing from one child's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee to collect signed and darted Emergency Medical Consent form for children in care. Going forward, licensee will ensure all children enrolled will include their Consent for Emergancy Medical Treatment forms.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 05/12/2023 11:58 AM - 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that signed copy of receipt from parent for Parents Rights form LIC995 missing from two children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee to collect signed and dated forms confirming receipt of Parent's Rights form for children in care. Going forward, licensee will ensure to collect the signed and dated Parents Rights proof of receipt.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 05/12/2023 11:58 AM - 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: WILSON, DANA
FACILITY NUMBER: 013421935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one child's file was missing a signature on the LIC282 form acknowledging licensee does not carry liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee to collect signature of form LIC282 from parent Acknowledging licensee has no liability insurance. Going forward, licensee will ensure to collect the signed and dated LIC282 form for all children in care.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that a newly admitted infant into care did not have the Infant Safe Sleep form LIC9227 in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee to collect completed with signature and date the LIC9227 Infant Safe Sleep Plan for the child in care. Going forward, licensee will ensure to collect the Infant Safe Sleep Plan for all infants in care aged birth to 12 months.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8