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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405375
Report Date: 07/29/2019
Date Signed: 07/29/2019 11:51:33 AM

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:MCCULLOUGH, KIMFACILITY NUMBER:
073405375
ADMINISTRATOR:MCCULLOUGH, KIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 374-9893
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:14CENSUS: 6DATE:
07/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Doris Reddit and Kim McCulloughTIME COMPLETED:
12:15 PM
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An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Met with Kim McCullough. Visit began at 9:15 AM. She is here with her helper. There are 7 adults fingerprint clear and associated with the facility. There are 6 children present. One child is an infant, three are school age and two are preschoolers. CPR and First Aid are current for Kim McCullough and her helper. Children's records were reviewed.

The home has 2 bedrooms and one bath. Both bedrooms are off-limits. Children use the bathroom in the hall. It contains no hazards. Day care is done in the living room and dining area. There is no outside play space. Children are taken to a nearby park for outdoor play. There are adequate toys and equipment for children in care. The family has no pets. There are no bodies of water. There is a currently charged fire extinguisher and working smoke alarm and carbon monoxide detector. First aid materials available. There is no fireplace. The home has central heat. Electrical outlets are covered. There no hazards observed in the home. Required forms are posted. Kim McCullough states that there are no guns or firearms in the home or any of the off limits spaces. First Aid kit is on top of the refrigerator.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
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 2
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: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375
VISIT DATE: 07/29/2019
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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 Kim McCullough states that there are no children needing incidental medical Services at this time.

The following were issued and discussed: Licensee Rights, Safe sleep concepts for children, Safe and healthy diapering, car seat information, fire and earthquake drills information, blue immunization form, AB 1207 information, Department Quarterly updates and flu prevention tips.

No deficiencies are cited. An exit interview was given.

SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2