013422740-9-16-2021-52-CC-RHAR-C6WQVS-20210916123050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422740
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:31:02 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:	BERGENDAHL, S. ANNETTE		FACILITY NUMBER:	013422740
ADMINISTRATOR:	BERGENDAHL, S. ANNETTE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 304-9570
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	14	CENSUS: 9	DATE:	09/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:			TIME COMPLETED:	12:45 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 September 16, 2021 at approximately 8:05am Licensing Program Analyst (LPA) Russ Haderer met with licensee Annette Bergendahl for the purpose of conducting an unannounced 1-year annual inspection for Health and Safety compliance. Present for today’s inspection was the licensee, two TB and fingerprint cleared assistants and 8 children in care; one infant, three 2-year old; one 3-year old; three 4-year old and additional infant arrived during the inspection). The hours of operation remain Monday-Friday, 7:00 AM to 6:30 PM. The facility is a 3 bedroom, two bath single story home with an attached 2-car garage. It is rented by the licensee and contains a living room, dining room, kitchen, 3 bedrooms (including master bath), enclosed (fenced) backyard play area. There is a fireplace in the living room with a screen. The home is neat and clean with heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in middle bedroom next to the house bathroom away from the other children in care. On-limit include: Kitchen, dining room, living room, daycare room (1st bedroom to right in hallway), main house bathroom, backyard, master bedroom and middle bedroom (next to the house bathroom) which is only used for napping infants in cribs. 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. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area. Off-limits include: Attached 2-car garage, locked shed and locked storage unit in backyard, both gated side yards and front yard (other than to walk through for drop off and pick up times). Off limit areas are inaccessible by closed and/or locked doors and visual supervision.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: BERGENDAHL, S. ANNETTE	FACILITY NUMBER: 013422740
	VISIT DATE: 09/16/2021

NARRATIVE

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Disaster drills are conducted at least every six months (twice per month), the last one was done September 7, 2021. Per licensee, there are no firearms in the home. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection. The back yard play area has age appropriate toys and playhouse structures with a patio and grass area. Licensee has a first aid kit in the main house bathroom.

Licensee has ample age-appropriate toys and learning materials in the home. There are two fully charged fire extinguishers, 2A10BC and 3A40BC both recently inspected by the fire department on September 14, 2021. There is a working smoke and carbon monoxide detector (tested and functioning), and a working telephone.

The Licensee’s Health and Safety training is completed, and CPR and First Aid certificate is current and expires 06/12/2023. The licensee completed and received a certificate in mandated reporter training (verified AB1207), expires on 11/08/2022. Both assistants have current CPR/1^st aid certificates expiring June 2023 and Mandated Reporter certificates are also current. The licensee and assistants are in compliance with the immunization laws which pertains to day care providers.

LPA reminded the licensee of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

At 10:00am, LPA reviewed children’s and facility files. Some children had nebulizer forms signed by parents as a precaution due to family history, per licensee, only one child requires an inhaler at this time. The medication was checked and not expired. All files complete and well organized. Licensee does not carry liability insurance. All children’s files contained signed acknowledgement forms from parents regarding liability insurance.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: BERGENDAHL, S. ANNETTE	FACILITY NUMBER: 013422740
	VISIT DATE: 09/16/2021

NARRATIVE

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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 [or facility representative] 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 [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.

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.

There were no deficiencies issued during today’s inspection.

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

Exit interview conducted and report was reviewed with the licensee Annette Bergendahl.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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