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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406098
Report Date: 06/08/2023
Date Signed: 06/08/2023 03:56:24 PM


Document Has Been Signed on 06/08/2023 03:56 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
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) 325-1050
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:14CENSUS: 8DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Donise KellerTIME COMPLETED:
04:15 PM
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On 6/8/2023, Licensing Program Analyst (LPA) Melanie Otsuji, met with Licensee Donise Keller for an UNANNOUNCED REQUIRED 1-YEAR INSPECTION. Present during today's visit were two fingerprint cleared assistants and 8 children (3 infants, 2 preschoolers, 3 school age). Facility hours of operation are Monday through Friday 6:00AM - 6:00PM. The home was toured to conduct a Health and Safety Inspection.

This is a single story home. The home is neat and clean and has heating and ventilation for safety and comfort. ON LIMIT AREAS: living room, family room, front office/nursery/hallway bathroom. All other rooms are off-limits. The off-limit areas will be inaccessible by closed and/or locked doors. There are toys and learning equipment. There is a hot tub in the backyard that is covered and locked. The home has a fully charged fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and First Aid Kit. Per licensee, there are no firearms in the home. Licensee has current CPR/First aid which expires 6/2025. Mandated reporter certificate was reviewed. Licensee and all staff have current mandated reporter certification.

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.htmhttp://www.ada.gov/childqanda.htm
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (559) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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: KELLER, DONISE
FACILITY NUMBER: 073406098
VISIT DATE: 06/08/2023
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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.

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.

No deficiencies noted on today's date. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Donise Keller.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (559) 341-5559
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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