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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405375
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:42:34 PM


Document Has Been Signed on 09/15/2022 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 7DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 AM
MET WITH:Kim McCulloughTIME COMPLETED:
04:55 PM
NARRATIVE
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On Thursday, September 15, 2022 12:49 PM, Licensing Program Analyst (LPA) Caroline Colson met with Kim McCullough, for an unannounced random annual inspection. There are 3 preschool children and 1 infant present. Additional children arrived during the inspection. Licensee picked up 2 school age children and 1 preschool child. The home was toured to conduct a health and safety inspection. Hours of Operation are Monday-Friday from 7:00 AM - 8:30 PM.

Indoor Space: The home is a one story home. The home consist of a living room, dinning room, kitchen, two bedrooms, one bathroom, fenced back yard and garage. The home has a 2A10BC fire extinguisher, a working smoke detector and a working carbon monoxide detector. There is one screened wall heater. Licensee states there are no firearms in the home. The isolation area is the hallway. Her infant CPR and First Aid certificates are current and expire on July 27, 2024. Licensee will follow up with the agency who provided her with the CPR/First Aid class to obtain the EMSA approved stickers. She has a first aid kit. There are no pets.

Outdoor Play Space: Licensee takes the children to the neighborhood park for outdoor play.

Off Limit Areas: The off limit areas are both bedrooms, kitchen, fenced back yard and garage.


Please LIC 809 C for Additional Information
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2020
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 6


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: 09/15/2022
NARRATIVE
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 CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov



· Licensees may register to receive child care updates: www.myccl.ca.gov

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 ADA, available at: http://www.ada.gov/childquanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Family Child Care Homes

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


Please See LIC 809 C for Additional Information
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375
VISIT DATE: 09/15/2022
NARRATIVE
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Safe Sleep

LPA discussed the safe sleep regulations with Kim McCullogh and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Karla Sparks-Hunter of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

There were deficiencies cited during this inspection.

Notice of Site Visit

A notice of site visit was given and must remain posted for 30 days.

Exit Interview

Exit interview conducted and report was reviewed with the licensee, Kim McCullough.

Please See LIC 809 D for Deficiencies

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/15/2022 04:42 PM - It Cannot Be Edited

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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because the licensee does not have a current certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2022
Plan of Correction
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Licensee is scheduled for an upcoming class and will send a copy when completed.
Section Cited
Administration of Child Day Care Licensing
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/15/2022 04:42 PM - It Cannot Be Edited

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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because four children didn't have the LIC 700 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2022
Plan of Correction
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Licensee was given a copy of the form to give to each parent to complete.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because four children didn't have immunization records. One child had immunization records but wasn't on the California School Immunization which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2022
Plan of Correction
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Licensee was asked to document the immunization record on the California School Immunization form.

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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/15/2022 04:42 PM - It Cannot Be Edited

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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2022
Plan of Correction
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Licensee was given a copy of the Parent's Right to give to all parents.

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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6