<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073404452
Report Date: 09/06/2019
Date Signed: 09/06/2019 01:33:41 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:HARRIS, THERESAFACILITY NUMBER:
073404452
ADMINISTRATOR:HARRIS, THERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 233-8328
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY:14CENSUS: 11DATE:
09/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Harris, TheresaTIME COMPLETED:
02:00 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
3 Licensing Program Analyst, (LPA), R. Hollie, met with Licensee for the purpose of a Random Health and Safety Inspection. Present is the licensee, her husband at the beginning of the visit, two staff, Martina and Emily, both fingerprinted and 11 children, four infants seven preschoolers. The OFF LIMITS of the home remain upstairs with a gate at the bottom of the stairs. Children have access to the Family Room, two bedrooms, living room and all located downstairs.
Per the Licensee, there are no bodies of water on the premises nor are there guns on the premises. Poisons, detergents, cleaning compounds and medications are inaccessible to children. There is a working smoke detector and a charged fire extinguisher (2a10bc) as well as a carbon monoxide detector. The home has toys, play equipment and materials for children. The licensee understands that children are to be supervised at all times. The licensee is aware that children are not to be locked in cars or other areas of the home. The licensee was informed that when or if she is temporarily absent from the home, a fingerprint cleared adult, who holds a current CPR/FA must be present in her absence. The licensee shall always maintain the capacity specified on the license. PLEASE SEE NEXT PAGE FOR CONTINUED REPORT.
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019
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 4
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: HARRIS, THERESA
FACILITY NUMBER: 073404452
VISIT DATE: 09/06/2019
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
26
27
28
29
30
31
32
LPA DISCUSSED WITH LICENSEE THAT AS OF SEPTEMBER 1, 2016, ANY PERSON(S) EMPLOYED OR VOLUNTEERING AT A FAMILY DAY CARE HOME SHALL BE IMMUNIZED AGAINST INFLUENZA, PERTUSSIS AND MEASLES OR MUST QUALIFY FOR AN EXEMPTION. LPA INFORMED THE LICENSEE IF PERSON’S DO NOT WISH TO OBTAIN AN INFLUENZA VACCINE, A WRITTEN STATEMENT DECLINING THE FLU SHOT MUST BE AVAILABLE DURING THE VISIT. LPA discussed and advised licensee to check in with parent or guardians if children fail to arrive to the day care as scheduled. LPA encouraged the Licensee to review our website at the above address at CCLD.CA.GOV to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business, Particularly, the Provider Information Notices, known as PINS.

THE LICENSEE WAS PROVIDED A COPY OF THEIR APPEAL RIGHTS (LIC 9058 12/15) AND THEIR SIGNATURE ON THIS FORM ACKNOWLEDGES RECEIPT OF THESE RIGHTS. LPA POSTED THE REQUIRED POSTINGS FOR PUBLIC VIEWING.The licensee as informed that if the facility receives a deficiency, the facility must make the corrections by the date on the report (809-d) or the facility will receive a penalty of $100 per day until the deficiency is corrected. The Licensee was made aware of Safe Sleep Regulation Concepts as it relates to Infants. During the visit, the Licensee was given a copy of the document containing the Sleep Regulation Concepts. As a one time courtesy, the licensee was given Technical Advise regarding children immunization. During the visit, LPA discovered that the licensee does not have the required packet for one of the newly enrolled day care children. SEE 809-D FOR TYPE B DEFICIENCY.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HARRIS, THERESA
FACILITY NUMBER: 073404452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2019
Section Cited

1
2
3
4
5
6
7
CHILD'S RECORDS a,b,c The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).(1)The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child.
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7).
THIS REQUIREMENT HAS NOT BEEN MET
8
9
10
11
12
13
14
The Licensee does not have required paperwork for a newly enrolled child, particularly, consent for medical treatment and, ID information
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: HARRIS, THERESA
FACILITY NUMBER: 073404452
VISIT DATE: 09/06/2019
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
26
27
28
29
30
31
32
The home appears to have healthful, safe and comfortable accommodations, furnishings and equipment for children. There is a current roster of the children. The home conducts fire and disaster drills, per the licensee. The licensee provides parents with a Notification of Parents Rights.
The Licensee understands that unannounced visits by CCL Employees, provided ID is shown and in the course of business, may enter and inspect areas of her home where she provides personal care and services to children.
The licensee understands that upon notice of the Department to remove an individual from the home, pursuant to H&S Code 1596.871(c)(2) or to exclude an individual from the home, pursuant to H&SCode 1596.8897, the licensee immediately removes the individual and prevents them from returning to the home or having contact with children in care. The licensee must ensure that all adults working, residing or volunteering in a licensed home, must obtain a criminal record review (fingerprint clearance) prior to being in the presence of children.
The licensee has current CPR/FA which expires 20/20. A sampling of Children's records were reviewed during this visit.

Incidental Medical Services (IMS) policy was discussed. The licensee is not currently caring for any children that require IMS services today.

PLEASE SEE NEXT PAGE FOR CONTINUED REPORT

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4