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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405375
Report Date: 09/17/2019
Date Signed: 09/17/2019 05:24:02 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:MCCULLOUGH, KIMFACILITY NUMBER:
073405375
ADMINISTRATOR:MCCULLOUGH, KIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 374-9893
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:14CENSUS: 9DATE:
09/17/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sabina Mitchell and Kim McculloughTIME COMPLETED:
05:30 PM
NARRATIVE
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An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Initially met with Sabina Mitchel. Kim Mccullough arrived later. Visit began at 3:15 PM. She is here with two helpers. There are 9 adults fingerprint clear and associated with the facility. There are 9 children present.

The home has 2 bedrooms and one bath. Both bedrooms are off-limits, according to Kim McCullough although they were open during this visit and the previous visit.. Some children were transported in a 12 passenger van which was driven by Sabing Mitchell.

Deficiencies are cited on LIC 809 D.

Appeal Rights were discussed.

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: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2019
Section Cited

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Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but
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are not limited to, the following:(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This was not met in that car seats in the van were not properly secured and children needing them were transported today.
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Type A
09/18/2019
Section Cited

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Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include but
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are not limited to, the following:(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This was not met in that both off-limits bedrooms were open and accessible today and during last visit.
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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: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2019
LIC809 (FAS) - (06/04)
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