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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422888
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:42:22 PM


Document Has Been Signed on 01/24/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:PETERSON, KRISTINAFACILITY NUMBER:
013422888
ADMINISTRATOR:PETERSON, KRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 921-7885
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 9DATE:
01/24/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kristina PetersonTIME COMPLETED:
04:00 PM
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On January 24, 2024, at 1:45 PM, Licensing Program Analyst (LPA) Elimika Woods met with licensee Kristina Peterson for an Unannounced Required 3 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection was the licensee's fingerprint cleared assistant, Shelia Guidry, five (5) preschool age children, and four (4) infants. Licensee stated that the facility operates from Monday to Friday 7:00 AM to 5:30 PM.

LPA toured the facility inside and outside to conduct a Health and Safety inspection. This single story home was clean and orderly, with heating and ventilation for the safety and comfort. The Isolation area of the home will be a section of the living room, away from other children in care.

The off-limits are will be made inaccessible by closed and/or locked doors and visual supervision. There's a fire place in the living room and family room that has a barricade/screen to prevent access by children. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection.

The home has a working smoke detector, working carbon monoxide detector, first aid kit, telephone, and fully charged 2A10BC fire extinguisher which meets standards established by the State Fire Marshal. Per licensee, there are firearms in the home and the LPA verified that the firearms and ammunition are stored in an off-limits area of the home. LPA asked the licensee does she transport children and the licensee stated that she does not transport children.

On-limit-areas include: Living room, family room, kitchen, second bedroom at the end of hallway to the right, First bedroom on left side of hallway, bathroom on right side of hallway, laundry room, and backyard

Off-limit-areas include: First bedroom on right side of hallway, bedroom (2) at the end of hallway, Attic, and Garage

See 809-C for continuance
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PETERSON, KRISTINA
FACILITY NUMBER: 013422888
VISIT DATE: 01/24/2024
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The OUTDOOR PLAY area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. During today's inspection, there are no play structures which are required to be anchored. There are ample age appropriate toys that appear to be safe and in good condition. There's a small play structure with cushioning underneath to absorb children falls. The backyard has a canopy for shade and tables and chairs for children to sit down and relax during and after play.

At 2:00 PM LPA requested and reviewed the files of three (3) children in care. All children files contain Immunization, Parent's Rights, and Medical Consent forms. The facility roster was reviewed, and copies were obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 10/17/23. The licensee and her assistants Health and Safety training is completed, and CPR and First Aid certificate is current and expires 03/2025. The licensee has completed mandated reporter training on 03/30/23 and her assistant has completed hers on 02/25/23. The licensee is in compliance with the immunization laws which pertains to all childcare providers. All required forms are posted and visible for public review. The licensee is in ratio today

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

See 809-C

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PETERSON, KRISTINA
FACILITY NUMBER: 013422888
VISIT DATE: 01/24/2024
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Kristina Peterson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Kristina Peterson.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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