073402173-1-16-2020-02-CC-PPEN-BKVS3H-20200116123109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073402173
Report Date: 01/16/2020
Date Signed: 01/16/2020 12:31:16 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:	SIMS-CARR, KISA		FACILITY NUMBER:	073402173
ADMINISTRATOR:	SIMS-CARR, KISA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 222-2266
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94806
CAPACITY:	14	CENSUS: 9	DATE:	01/16/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kisa Sims-Carr		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Paul Petersen conducted an unannounced random annual site inspection for this facility at 0940. LPA met with licensee, Kisa Sims-Carr. Also present at the time of this inspection were assistant, Deanna Johnson, and there were nine children in care consisting of three infants, five preschool age and one school age children including five grandchildren. The facility is within ratio and capacity. Licensee's husband, Raechell Carr, arrived at the facility while LPA was still present. All adults present are background cleared and associated to this facility. The on limits areas of the home for children in care are the living room, kitchen, bathroom in the hall, one bedroom, the family room and converted garage. The facility has been inspected by fire department within the past year. Off limits areas are made inaccessible by closed doors and visual supervision. There is a fireplace which is screened to prevent access by children. There are age appropriate furnishings, play items and equipment (including infant sleeping equipment) which appear to be free of hazardous conditions. Hazardous items/toxins are stored inaccessible to children in care via child safety latches or high cabinets. There are working fire alarms, a working carbon monoxide detector and fully charged 3A40BC fire extinguisher. Per licensee there are no firearms present or stored on the premises. The back patio and outdoor area is off limits to children in care and licensee will contact LPA prior to returning the out doors area to on limits. There are no pools, hot tubs or other bodies of water accessible to children. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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 Continued on Page 2**************************************************************************************

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020

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: SIMS-CARR, KISA	FACILITY NUMBER: 073402173
	VISIT DATE: 01/16/2020

NARRATIVE

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LPA and licensee reviewed documents received by licensee from CDSS regarding licensee's adult daughter, Lanisha Carr. LPA received copies of the following documents; Decision and Order, Notice of Defense, Statement of Respondent and Request for Discovery which LPA will seek further information on from Regional Office Management and forward any supplemental information to licensee.

LPA reviewed the facility and children's records including parents' rights forms, emergency ID forms and immunization records. Licensee has current CPR/First Aid certification which expires 02/2021.
LPA reviewed with licensee the current Facility Personnel Report Summary and verified that all adults requiring background clearances are cleared and associated to this facility.

The Safe Sleep Awareness Campaign PIN packet was provided and reviewed. Licensee is encouraged to visit www.ccld.ca.gov for licensing regulations and forms. To sign up for quarterly updates contact: childcareadvocatesprogram@dss.ca.gov. Licensee is reminded that Mandatory Reporter Training is to be renewed every two years.

There were no deficiencies cited during this inspection. A notice of site visit was provided and is to be posted for 30 days. A copy of this report is to remain in the facility records for a period of three years from today's date.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020

LIC809 (FAS) - (06/04)

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