073404452-4-8-2020-02-CC-PPEN-BNGUDU-20200408153007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073404452
Report Date: 04/08/2020
Date Signed: 04/08/2020 03:30:23 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, THERESA		FACILITY NUMBER:	073404452
ADMINISTRATOR:	HARRIS, THERESA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 233-8328
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94805
CAPACITY:	14	CENSUS: 3	DATE:	04/08/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Teri Harris/Randi Hartwell		TIME COMPLETED:	02:40 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	Licensing Program Analyst (LPA) Paul Petersen conducted a tele-video site inspection for approval of an emergency waiver request for temporary relocation of this facility to 17 Olinda Ct, El Sobrante, CA. 17 Olinda Ct, El Sobrante, is owned by licensee's daughter, Randi Hartwell, who was present during this tele-video inspection along with licensee, Teri Harris. Also present at the residence at the time of this inspection were licensee's son-in-law, Aaron Hartwell, and licensee's three grandchildren (12, 10 and 3 years old). A temporary waiver is on file for relocation of child care services to 17 Olinda Ct, El Sobrante. All areas of the residence were toured via Facetime tele-video connection. The areas of the residence on-limits to children in care will be the Living Room and Dining Area, the Family Room, the Kitchen and the Hallway Bathroom, all located in the main house, and the Back Play Room which is detached from the main house. There is a working smoke detector, a working carbon monoxide detector and a fully charged fire extinguisher present. The fireplace is screened to prevent access by children. Hazardous items/toxins are inaccessible to children in care via child safety fasteners on cabinets and drawers. Per licensee's daughter, there are no firearms present or stored on the premises. The outdoor patio/backyard area is fully fenced and will be on limits to children in care with adult supervision present at all times children are using the outdoor area. There are no pools, hot tubs or other bodies of water accessible to children in care. There are no pieces of high climbing equipment or swings present. The outdoor storage shed is to remain locked and inaccessible to children in care. The garage is off limits to children in care. 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: 04/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2020

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: HARRIS, THERESA	FACILITY NUMBER: 073404452
	VISIT DATE: 04/08/2020

NARRATIVE

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LPA and licensee reviewed all required postings including the waiver. Terms of the waiver were reviewed. Licensee and licensee's daughter have current CPR/First Aid certification. Licensee will be the primary care provider at this relocation. All adults living at this location are background cleared and associated to this facility.

The temporary relocation is approved for location: 17 Olinda Ct, El Sobrante, CA, effective 04/08/2020.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2020

LIC809 (FAS) - (06/04)

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