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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403315
Report Date: 09/19/2019
Date Signed: 09/19/2019 12:19:38 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:SURNEY, RHUNETTFACILITY NUMBER:
073403315
ADMINISTRATOR:SURNEY, RHUNETTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 754-6272
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:14CENSUS: 0DATE:
09/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:RHUNETT SURNEYTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Tasha Alexander met with licensee Rhunett Surney for an unannounced ANNUAL/RANDOM inspection. Licensee is the only one present for the inspection. Licensee cares for children with special needs. Today the facility is closed. LPA toured the facility and backyard for a health and safety inspection. The children's files contained emergency information. The home is equipped with a 2A10BC fire extinguisher, working smoke detector and working carbon monoxide detector. There is a working telephone in the home (number has been changed). LPA will update upon return to the office. Per licensee there are no fire arms on the premises. There are no pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children. Licensee has current CPR and 1st Aid training which expires 1/2021 respectively. The off limits areas are master bedroom, office and garage. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
A review of staff records on 9/19/19 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016 a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Today licensee is up to date on flu vaccination. records for pertussis is in file. no records for mmr

The newly mandatory mandated reporter training course was discussed. Licensee has not completed the course as of today. Licensee is unable to locate her certificate.

The new safe sleep practices for infants was also discussed. Licensee does not care for infants. The safe sleep practices form was given for reference. CONTINUED ON 809-C

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SURNEY, RHUNETT
FACILITY NUMBER: 073403315
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2019
Section Cited

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1597.622 Employee and Volunteer Immunization
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
REQUIREMENT WAS NOT MET: TODAY LICENSEE IS NOT ABLE TO LOCATE HER RECORDS FOR MMR VACCINATION
Type B
10/11/2019
Section Cited

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1596.8662 Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion
(b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter trainin
REQUIREMENT WAS NOT MET: LICENSEE IS UNABLE TO LOCATE HER MANDATED REPORTER CERTIFICATE

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: SURNEY, RHUNETT
FACILITY NUMBER: 073403315
VISIT DATE: 09/19/2019
NARRATIVE
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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

The attached type B deficiencies are cited today and must be corrected by the due date. An exit interview was conducted. This report must be available for public review for 3 years. A notice of site visit was posted.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3