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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405375
Report Date: 04/05/2024
Date Signed: 04/05/2024 03:18:51 PM


Document Has Been Signed on 04/05/2024 03:18 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
OAKLAND CC RO, 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: 4DATE:
04/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kim McCulloughTIME COMPLETED:
03:40 PM
NARRATIVE
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On 4/5/2024, at 11:45AM Licensing Program Analyst (LPA) Brittany Crass arrived at the home for an unannounced required/random inspection. LPA met with licensee Kim McCullough. There were 3 preschool aged children, and one school aged child in care during the inspection. Also present upon arrival was a non-fingerprinted adult whom the licensee stated was there for an interview. There are no pets. This family childcare home operates Sunday - Friday 7AM-6PM. The licensee does not provide overnight care. The licensee transports the children. LPA verified that the licensee's phone number and email address on file are correct.

LPA toured the on-limits areas of the home with the licensee, to conduct a health and safety inspection. The home is a single story home, with a lower garage level. LPA observed that the home is neat and clean with heating and ventilation for the safety and comfort of children in care. The on-limit areas include the living room, dining area, and bathroom. The off-limit areas are made inaccessible by closed and/or locked doors, gates, and visual supervision. The dining area is used for isolation of sick children, away from other children in care. The heater in the living room is blocked to prevent access by children. The backyard is off-limits and the licensee walks the children to a nearby park for outdoor play. LPA observed an ample supply of age-appropriate toys, equipment and activities available for children and observed that they are in good condition. LPA did not observe any bodies of water, toxins, medications or hazardous items that would be accessible to children. The licensee stated that there are no firearms on the premises.

The home is equipped with fully charged 2A10BC fire extinguisher, a working carbon monoxide detector, working smoke detector, and a working telephone. Licensee has proof of current CPR/First aid certificates, which expire on 10/22/2024, and a Mandated Reporter Training certificate which expires on 10/20/2024. LPA observed all of the required forms posted. LPA reviewed children's files, and obtained a copy of the current roster.

(Report continued, See 809-C).

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375
VISIT DATE: 04/05/2024
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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.

LPA reminded the licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. LPA provided the main office number for the Oakland Regional Child Care office (510) 622-2602 for the licensees to call and report injuries or unusual incidents and reviewed the form to follow up in writing within 7 days of the injury/unusual incident. The licensees were encouraged to periodically review regulations, guidelines and Provider Information Notices (PINs) on the website www.ccld.ca.gov

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

(Report continued, See 809-C).

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375
VISIT DATE: 04/05/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

During the exit interview, the licensee Kim McCullough, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA reminded the licensee that the mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

See 809-D for deficiencies cited during todays visit.

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

Appeal rights provided and discussed.

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

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/05/2024 03:18 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 childrens files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will have the parents of all enrolled children complete the LIC 700 by 4/12/2024, and will email LPA the copies.
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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4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 children in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will have the parents of all children in care fill out the Consent for Emergency Medical Treatment Form (LIC 627) for all children in care by 4/12/2024, and will email LPA a copy.
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) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 04/05/2024 03:18 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

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). (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 interview and record review, the licensee did not comply with the section cited above in 3 out of 4 childrens files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will have the parents complete the Notification of Parents Rights form (LIC 995A) for all children in care by 4/12/2024, and will email LPA a copy.

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) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 04/05/2024 03:18 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 childrens files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 04/05/2024 03:18 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: MCCULLOUGH, KIM
FACILITY NUMBER: 073405375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
The licensee shall document each childs immunizations are 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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 childrens files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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2
3
4
The licensee will obtain immunizations records, and add them to the blue form for all children by 4/12/2024, and will email LPA a copy of the record.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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) 622-2602
LICENSING EVALUATOR NAME: Brittany CrassTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9