013421970-5-3-2019-52-CC-SKAR-BBTRJB-20190503130341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421970
Report Date: 05/03/2019
Date Signed: 05/03/2019 01:03:45 PM

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:	HENDRICKS, LISA		FACILITY NUMBER:	013421970
ADMINISTRATOR:	HENDRICKS, LISA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 339-4121
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	14	CENSUS: 11	DATE:	05/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lisa Hendricks		TIME COMPLETED:	01:20 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 5/3/19, Licensing Program Analyst (LPA) Simerjit Kaur, met with licensee Lisa Hendricks for an UNANNOUNCED ANNUAL RANDOM INSPECTION. The home was toured for Health and Safety Inspection. Present for this inspection is licensee's fingerprint cleared and associated wife (assistant) Sally Scrutchin, 3 infants, and 8 preschool age children in care. The home is single story. The ON LIMIT AREAS are the living room, day care room, bathroom in the hallway and backyard on right side only. The OFF LIMIT AREAS are master bedroom, 2 bedrooms located in the hallway, kitchen, left side of the backyard and garage, which will be inaccessible by closed and/or locked doors and visual supervision. The licenee use 3 bedrooms for nap time only. The ISOLATION AREA will be the living room. The BACKYARD play area is fenced. There are toys. It was observed that there are no toxins or hazardous items accessible during the inspection. During the inspection, it was also observed there are no pools, hot tubs or any bodies of water on premises. The home has a fully charged with 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee's CPR and First Aid certificate is current and expires 01/05/21. Licensee is in compliance with the immunization law which pertains to day care providers. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The last conducted fire and disaster drill was documented on 03/12/19. Required licensing documents are posted. Incidental Medical Services were discussed. Licensee will submit an updated plan of operation if in the future she provides any IMS services to a child in care. Per licensee, there are no children on any type of prescription medications today. See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Simerjit Kaur	TELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

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: HENDRICKS, LISA	FACILITY NUMBER: 013421970
	VISIT DATE: 05/03/2019

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LPA reviewed (5) Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. Safe sleep regulation information was discussed.

California Law requires Family Child Care Home licensees to Report Unusual incidents or injuries to children in care to the child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Do not leave an Unusual Incident Report on the Licensing Program Analyst voice mail.

LPA informed licensee of Assembly Bill 1207, the mandated reporter training which can be found at www.mandatedreporterca.com.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov.

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

No deficiency cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Simerjit Kaur	TELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019

LIC809 (FAS) - (06/04)

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