070211010-1-29-2020-02-CC-MGUT-BLARVK-20200129122141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070211010
Report Date: 01/29/2020
Date Signed: 01/29/2020 12:21:46 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	SMITH, NICOLETTE		FACILITY NUMBER:	070211010
ADMINISTRATOR:	SMITH, NICOLETTE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 758-4092
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	12	CENSUS: 7	DATE:	01/29/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nicolette Smith		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 01/29/2020, Licensing Program Analyst (LPA), Melissa Guirit, met with licensee's two assistants, Jean and Stephanie upon arrival for an UNANNOUNCED RANDOM INSPECTION. Licensee arrived at 11:45 AM. Present for this inspection were licensee, fingerprint cleared assistants, Jean and Stephanie, 1 infant, and 6 preschooler. The home was toured to conduct a Health and Safety Inspection. The facility's hours of operation are from 7:00 AM to 6:00 PM. The home is single story. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the kitchen/dining area, living room, first bedroom on the right of the hallway, hallway bathroom, and backyard. The OFF LIMIT AREAS are the rest of rooms and garage which will be inaccessible by closed and/or locked doors, safety gates, and visual supervision. The ISOLATION AREA will be in the on limits bedroom in the hallway. The outdoor play area is free from defects or dangerous conditions and is completely fenced with 100% supervision. The play structure located in the backyard is in good condition and has an ample amount of cushion in case of a fall. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and fully stock First Aid Kit. The licensee and assistants' CPR and First Aid certificates are current and expires 10/2020. Licensee and assistants completed the Mandated Reporter Training which expires on 12/2020. The licensee and assistants are in compliance with the new immunization law. Per licensee and assistants, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one on 10/11/2019. See 809-C for continuance.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020

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: SMITH, NICOLETTE	FACILITY NUMBER: 070211010
	VISIT DATE: 01/29/2020

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At 11:30 AM, (7) Children files were reviewed, (2) staff files reviewed, facility roster reviewed and copy obtained. All reviewed children files had updated immunization records and signed Parents' Rights. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

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. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov .http://www.myccl.gov/

Incidental Medical Services (IMS) policy was discussed.

There are no deficiencies cited. 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 and appeal rights provided.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020

LIC809 (FAS) - (06/04)

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