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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406098
Report Date: 01/31/2020
Date Signed: 01/31/2020 03:17:02 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:KELLER, DONISEFACILITY NUMBER:
073406098
ADMINISTRATOR:KELLER, DONISEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 978-9045
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:14CENSUS: 6DATE:
01/31/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:DONISE KELLETIME COMPLETED:
03:00 PM
NARRATIVE
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LPA Tasha Alexander met with licensee Donise Keller for an unannounced ANNUAL/RANDOM inspection. Present for the inspection were licensee, 2 assistants Teyah Brown and Brandy Wallick along with 6 children in care, consisting of 3 infants and 3 preschoolers. LPA toured the facility and backyard for a health and safety inspection. The children's files contained emergency information. The home is equipped with a 2A10BC fire extinguisher, working smoke detector and working carbon monoxide detector. There is a working telephone in the home. Per licensee there are no fire arms on the premises. There are no pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children. Licensee has current CPR and 1st Aid training which expires 4/19/21. The off limits areas are 3 bedrooms, garage and laundry room. . Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
A review of staff records on 1/31/20 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Today licensee has immunization records in file. flu vaccination up to date. Both assistants need to provide immunization records.

The newly implemented mandatory mandated reporter training course was discussed today.
All staff have a certificate of completion in file dated 8/30/18, licensee is reminded to renew by 8/2020. Both assistants have a certificate of completion date 9/2019 and 1/2020

The new safe sleep practices for infants was also discussed today. There are 3 infants present today. There are 3 play pens available for infant sleeping.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
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 3
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: KELLER, DONISE
FACILITY NUMBER: 073406098
VISIT DATE: 01/31/2020
NARRATIVE
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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

The attached type B deficiencies are cited today and must be corrected by the due date. An exit interview was conducted. This report must be available for public review for 3 years. A notice of site visit was posted.



SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KELLER, DONISE
FACILITY NUMBER: 073406098
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2020
Section Cited

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1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
REQUIREMENT WAS NOT MET: TODAY BOTH ASSISTANTS DO NOT HAVE IMMUNIZATION RECORDS IN FILE.

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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: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3