073405420-7-27-2022-02-CC-NBLT-CGQP94-20220727110632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073405420
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:06:42 AM

Document Has Been Signed on 07/27/2022 11:06 AM - It Cannot Be Edited

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:	LEE, KRISTINE		FACILITY NUMBER:	073405420
ADMINISTRATOR:	LEE, KRISTINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 381-2848
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	14	CENSUS:	DATE:	07/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	LEE, KRISTINE		TIME COMPLETED:	11:30 AM

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On July 27, 2022 at 9:15 AM, Licensing Program Analyst (LPA) Nyeesha Blount met with Licensee Lee, Kristine and assistant Lilia Oyco for an unannounced random annual inspection. There are (2) preschool and (1) infant children present during the time of the inspection. the facility operating hours are Monday - Friday 8:30 AM to 5:00 PM. LPA toured all on limits areas of the facility for health and safety inspection. all required postings are posted in the entry way of the home.

The home consists of one kitchen, living room, dining room, four (4) bedrooms, (2) bathrooms, fenced back yard, front yard and garage. The home is neat and clean and has central heating and ventilation for safety and comfort. There is ample amount of age appropriate furnishings, toys, books available. Licensee states that there are no weapons in the home. All hazardous materials and toxins are stored away inaccessible to children in care at the time of the inspection .The home is equipped with a 3A40BC fire extinguisher, working smoke detector and working carbon monoxide detector. Pediatric CPR and First Aid are current and will expire on July 2023

. ON LIMIT areas of the home will be the portion of the kitchen, living room, dining room, bedroom to the right of the living room, bathroom to the right of the hall. OFF LIMIT areas of the home will be (3) bedrooms, (1) bathroom, Portion of the kitchen secured with a gate to make inaccessible to children and garage.

Outdoor Space: The fenced back yard is the outdoor play space. The entire area was inspected to ensure the health and safety of the area. all play structures are properly secured. There are no pools, hot tubs or any other bodies of water on the premises

Isolation Area : will be the first bedroom to the right of the living room.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha Blount	TELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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: LEE, KRISTINE	FACILITY NUMBER: 073405420
	VISIT DATE: 07/27/2022

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LPA reviewed the facility, staff and children's records including parents' rights forms, emergency ID forms and consent for emergency medical treatment forms. Licensee CPR/First Aid, Mandated Reporter Certificate for Licensee is all up to date.

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-and-resources/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. there are no firearms stored or present in the home.

Per 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

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.

Licensee was reminded about importance to stay in compliance with mandated reporter training and maintenance of sleep logs for all infants in care. In the areas that were evaluated, no regulatory violations were observed.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Lee, Kristine.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha Blount	TELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

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