013421970-7-8-2021-52-CC-RRED-C4QQ8Q-20210708115707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421970
Report Date: 07/08/2021
Date Signed: 07/08/2021 11:57:21 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 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:	07/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Lisa Hendricks		TIME COMPLETED:	12:30 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 7/8/2021, at approximately 9:55 AM Licensing Program Analyst (LPA) Renee' Reed, met with licensee Lisa Hendricks for an UNANNOUNCED 1 Year Inspection. Present for this inspection is licensee's fingerprint cleared wife (assistant) Sally Scrutchin, 4 infants, 3 preschool age 4 school age children in care. The home was toured for Health and Safety Inspection. Hours of Operation is Monday through Friday, 7:00 AM to 6:00 PM 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 licensee uses 3 bedrooms for nap time only. The ISOLATION AREA will be the living room. The BACKYARD play area is fenced. There are numerous 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 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 10/26/2021. Mandated reporter training is current for both Lisa and Sally. 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 6/17/2021. Required licensing documents are posted. Incidental Medical Services were discussed and Licensee is not providing IMS services. Licensee will submit a plan of operation if in the future she provides any IMS services to a child in care. See 809-C for continuance

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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: 07/08/2021

NARRATIVE

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

Mandated Reporter training is to be renewed every two years, CPR/First Aid is also to be renewed every two years.

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).

Baby bouncers & drop-down cribs are not allowed at the day-care facility. LPA discussed Unusual Incidents Reports.

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

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

Applicant 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.

There are no deficiencies 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: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

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