073404388-1-8-2020-02-CC-PPEN-BKMVLS-20200108153225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073404388
Report Date: 01/08/2020
Date Signed: 01/08/2020 03:32:37 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:	JOHNSON, TYISEN		FACILITY NUMBER:	073404388
ADMINISTRATOR:	JOHNSON, TYISEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 223-4574
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94803
CAPACITY:	14	CENSUS: 5	DATE:	01/08/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Tyisen Johnson		TIME COMPLETED:	03:40 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	License Program Analysts (LPAs) Paul Petersen and Russ Haderer met with Licensee Tyisen Johnson to conduct and annual random inspection on 1-08-2020 at 2:15pm. Licensee Tyisen Johnson was present as well as five children consisting of three preschool children and two school-age children. The facility is a two story home, the entire downstairs is on limits, and the entire upstairs is off limits. A gate is present at the bottom of the stairs to prohibit access to the upstairs. The on limits area includes a fully fenced backyard patio play area and an attached garage which has been converted to a daycare area and has been full approved by the fire department (permits available and posted). Fire alarms and carbon dioxide detectors were present and tested. The facility has two fully charged 3A40BC fire extinguishers. The outside play area has an off limits two-level hill that appears to be very gradually slowly slipping toward the back yard. It has retaining walls that are tilting toward the house, to ensure safety, licensee has been advised to be present when ever children are present in the backyard playing and to keep the children away from the hill area. The fence at the top of the property is becoming worn and will need to be replaced some time in the future. There are no swings or high climbing equipment present. Outdoor play items are free of observed hazardous conditions. There are no pools, hot tubs or other bodies of water accessible to children. All areas on limits to children in care were inspected for a health and safety inspection. There are child safety latches on kitchen cabinets. There are no hazardous items/toxins observed to be accessible to children in care. The home is clean and organized with heating and ventilation available for safety/comfort. There are age appropriate furnishings, play items and equipment (including infant sleeping equipment) which are free of observed broken/sharp pieces. Per licensee there are no firearms present or stored on the premises. 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: 01/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2019

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: JOHNSON, TYISEN	FACILITY NUMBER: 073404388
	VISIT DATE: 01/08/2020

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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 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

LPA reviewed the facility and children's records including parents' rights forms and children's immunization records. Licensee has current CPR/First Aid certification which expires 02/2021 All required postings are present. The facility roster was current. The disaster drill log is current.

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.

There were no deficiencies noted as of today's visit. A Site Visit Notice was issued and will remain posted for 30 days. A copy of this report will remain in the file for three years.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

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