013422325-4-28-2023-02-CC-ILOA-CRBNP5-20230428103747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422325
Report Date: 04/28/2023
Date Signed: 04/28/2023 10:38:02 AM

Document Has Been Signed on 04/28/2023 10:38 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	BULLOCK, LAURA		FACILITY NUMBER:	013422325
ADMINISTRATOR:	BULLOCK, LAURA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 672-5113
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94702
CAPACITY:	14	CENSUS: 0	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Laura Bullock		TIME COMPLETED:	10:43 AM

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 April 28, 2023 at 8:35am Licensing Program Analyst (LPA) Indira Loza met with Licensee Laura Bullock for an Unannounced Required Annual Inspection. Present during the inspection were the Licensee, her finger print cleared husband, and their underage child. The home was toured for a health and safety inspection. The facility operates from 9:00am – 5:00pm Monday – Friday. The home is a single story house consisting of three bedrooms and two bathrooms, a living room, kitchen, dining room, and a large backyard. The entrance to the day care is through the gate on the side of the house. The inside of the home was observed to be neat and clean with age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be inaccessible to the child in care. ON LIMITS AREA: The garage, which is used as an art room, the entire backyard, one bedroom inside the house which used as the playroom, the bathroom in the hallway, the dining room, and the living room. OFF LIMITS AREA: are two bedrooms and one bathroom ISOLATION AREA: is in the playroom inside the home The backyard has plenty age appropriate toys and activities for the children. LPA observed a large play structure, which was secured on the ground, with materials to absorb any falls. The children nap in the living room. The home has a fully charged 2A10BC fire extinguisher, a working combined smoke detector and carbon monoxide detector. The last fire drill was conducted on April 28, 2023. The Licensee provides two snacks and lunch is brought from home. Per Licensee, there are no firearms in the home. LPA reviewed both staff files and six children's files. LPA obtained a copy of the facility roster. The following was observed during the inspection - Both staff were missing a current Mandated Reporter Certificate *******************************Report Continues on LIC809-C*******************************

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira Loza	TELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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: BULLOCK, LAURA	FACILITY NUMBER: 013422325
	VISIT DATE: 04/28/2023

NARRATIVE

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- One person was missing a current CPR certificate

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02. 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 web page 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.
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/process.
See 809D for deficiencies that were cited during today's inspections.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted
Report and Appeal Right were provided to Licensee Laura Bullock.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira Loza	TELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2023 10:38 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BULLOCK, LAURA	FACILITY NUMBER: 013422325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as both staff did not have a current Mandated Reporter certificate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	LIcensee submit a current Mandated Reporter certificate for both staff no later than May 31, 2023.

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
1 2 3 4	Based on record review the licensee did not comply with the section cited above as no one in the home had a current CPR certificate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The Licensee shall submit a current CPR certificate to the LPA no later than May 31, 2023.

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: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira Loza	TELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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