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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070211010
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:14:20 PM


Document Has Been Signed on 06/20/2022 12:14 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:SMITH, NICOLETTEFACILITY NUMBER:
070211010
ADMINISTRATOR:SMITH, NICOLETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 334-4200
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:12CENSUS: 13DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nicolette SmithTIME COMPLETED:
12:30 PM
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On 06/20/2022 at 9:30 AM, Licensing Program Analysts(LPAs) Christina Watts and Ashley Curry conducted an unannounced annual inspection for Nicolette Smith family child care home. LPA met with licensee, Nicolette Smith and guided analysts on a tour of the facility. Also present for the inspection was 13 children, licensee's fingerprint cleared asisstant Stephanie Cowen, and licensee's sister who is visiting from out of town. Facility hours of operations are Monday-Friday from 7:00am - 5:30 pm.

This is a one story home which consists of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, garage, back yard with a play structure and a shed. The children will use the living room, kitchen, bathroom located at the end of the hall, first bedroom on the right, and the backyard. Areas off limits to children include: all bedrooms, master bathroom, and garage. The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating system for safety and comfort. There were safe toys, play equipment and materials observed for children. There are no stairs in the home. There is a working telephone in the home. Licensee is aware all sharp objects should be placed in an area inaccessible to children in care. Licensee is also aware all detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children should be stored in an area inaccessible to children. There is a dog, cat, parrot, and 2 fish tanks in the home.

LPA observed and inspected sleeping equipment. Per licensee, there are no weapons or firearms in the home. Licensee has an up to code 3A40BC fire extinguisher and working dual smoke/carbon monoxide detector on the premises. There are no fireplaces or open face heaters in family home. Licensee is aware that fire/earthquake drills must be completed and logged every 6 months.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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: 06/20/2022
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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-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.

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The licensees have current Pediatric First Aid and CPR certificate which will expire 06/07/2023. Required postings were observed near the entrance.

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) Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

On or before March 30, 2018 any person who works in a child care facility shall complete the Mandated Reporter training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.


Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: 06/20/2022
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 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.

At this time, there are no citations being issued today.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Nicollette Smith. A notice of site visit was given and must remain posted for 30 consecutive days.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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