013422888-5-6-2019-52-CC-LDYN-BBWVXM-20190506164945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422888
Report Date: 05/06/2019
Date Signed: 05/06/2019 04:49:51 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:	PETERSON, KRISTINA		FACILITY NUMBER:	013422888
ADMINISTRATOR:	PETERSON, KRISTINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 921-7885
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	14	CENSUS: 7	DATE:	05/06/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Kristina Peterson		TIME COMPLETED:	05:00 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 5/6/19 at 3:45pm, Licensing Program Analyst (LPA) Loretta Dyson arrived at the home for an unannounced random inspection. The licensee's fingerprint cleared assistant A. Quintal Cooper, 3 infants and 4 preschool age children, and the licensee's school age child were also present. At 3:50pm, LPA toured the areas of the home used for the child care, with the licensee. The home is a single story home, which is neat and clean with heating and ventilation for the safety and comfort of children in care. The on limit areas include the family room, living room, kitchen, bathroom on the right side of the hallway, the two bedrooms at the end of the hallway, and the laundry room. The off limit areas are made inaccessible by closed and/or locked doors and visual supervision. The isolation area is the living room, away from other children in care. The outdoor play area is the fenced backyard, which LPA observed to be free from defects or dangerous conditions. LPA observed an ample supply of toys and activities, which are age appropriate and in good condition, available for children. LPA did not observe any bodies of water, hazardous items or toxins accessible today. The home has a fully charged 3A40BC fire extinguisher, working combination smoke/carbon monoxide detector, telephone and first aid kit. The heaters are covered with a material that does not get hot to the touch, and the fireplace is gated to prevent access by children. LPA verified that the firearm and ammunition are stored in an off limit area of the home, and locked and stored separately. At 4pm, LPA reviewed 3 children's files, the assistant's file and the facility roster. A copy of the roster was obtained. The licensee has liability insurance thru her homeowner's insurance. Both the licensee and her assistant have current CPR/first aid certificates that expire on 2/23/21. LPA observed the interaction between adults and children. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to sign up to receive quarterly updates by email by sending a request to ChildCareAdvocatesProgram@dss.ca.gov. The Licensee was given a copy of A Child Care Provider's Guide to Safe Sleep pamphlet and LPA discussed safe sleep practices and policy. continued on 809C

SUPERVISOR'S NAME: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019

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: PETERSON, KRISTINA	FACILITY NUMBER: 013422888
	VISIT DATE: 05/06/2019

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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 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. LPA reviewed the individuals associated to the license, and the licensee confirmed that everyone who is required to have a criminal record clearance is associated. Licensee was reminded of the responsibility as a mandated reporter. The licensee has proof of completion of the required mandated reporter training for herself, dated 2/21/18. The licensee's assistants have also completed the training.

The licensee was reminded of the requirement for an assistant, at least 14 years of age, to be present in the home for a large family child care home. If an assistant is not present, the capacity requirement for a small family child care home must be followed.

There are no deficiencies being cited today. This report shall remain on file for 3 years. A Notice of Site visit was given to Licensee, and Licensee was reminded that it is required to be posted for 30 days. An exit interview was conducted.

SUPERVISOR'S NAME: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019

LIC809 (FAS) - (06/04)

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