<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406612
Report Date: 12/09/2022
Date Signed: 12/09/2022 12:48:42 PM


Document Has Been Signed on 12/09/2022 12:48 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:BLACKLOCK, ATCHAFACILITY NUMBER:
073406612
ADMINISTRATOR:BLACKLOCK, ATCHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 778-9172
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 13DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:BLACKLOCK, ATCHATIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On December 9, 2022 at 8:30 AM, Licensing Program Analyst (LPA) Nyeesha Blount met with Licensee Blacklock,Atcha, (2) assistants who is background cleared for an unannounced random annual inspection. There are (3) infants and (11) Preschool age children present during the time of the inspection. The facility’s operating hours are Monday -Friday 8:00AM to 5:30PM. LPA toured all on limits areas of the facility for health and safety inspection. All required postings were not posted.

The home is a one level consists of a living room, dining room, kitchen, (3) bedrooms, (1) bathroom, fenced backyard/patio, and garage. The home is neat and clean and has central heating and ventilation for safety and comfort. There are sufficient age appropriate furnishings, toys, books and learning materials 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 3A10BC fire extinguisher, working smoke detector, and Not working carbon monoxide detector. Pediatric CPR and First Aid has expired on 06/02/20.

ON LIMIT AREAS: will be living room, kitchen, bath room, play room, nap room,

OFF LIMIT AREAS: will be the first bedroom to the right in the living room. secured with locked door.

OUTDOOR SPACE: The backyard/patio. 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 during today's inspection.

ISOLATION AREA: will be the first bedroom to the right.

SEE LIC809C FOR CONTINUANCE…….

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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 44


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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612
VISIT DATE: 12/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA was unable to 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 currently expired.

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.

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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 44 of 44
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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612
VISIT DATE: 12/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 Regulatory violations were observed Pediatric/CPR expired, Carbon monoxide not working Mandated Reporter's Training expired, Capacity Ratio, fire drill log , sleep log, children & staff records not available during the time of inspection.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Blacklock,Atcha.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 44
Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above she was out of ratio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will decrease her ratio as soon as possible and watch a video on capacity and submit written statement how she will stay in complaince.
Type A
Section Cited
CCR
102416.5(d)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in Capacity ratio which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will make sure she decreases her ratio as as possible.LPA discussed the ration guidelines.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee was over capacity ratio which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will make the adjustments to remove some children and will advise LPA of the changes.
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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 an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will make the adjustments to remove some children and will advise LPA of changes.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(g)
Staffing Ratio and Capacity
(g) For the purpose of meeting the criteria in Sections 1597.44 and 1597.465 of the Health and Safety Code, for a school age child who is under age six, the licensee shall maintain documentation verifying the
child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary
school.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee had 3 Infants and 11 schoolage children out of capacity, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will make adjustments as soon as possible and advise LPA of changes. LPA advised Licensee that child #13 & 14 must be school age children.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not have a working carbon monoxide detector, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will send photo via email of carbon monoxide detector, licensee will come back out to inspect.
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
1
2
3
4
Based on [(observation) Licensee did not have current Mandated Reporter's training certificate present during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will complete Mandated Reporter's Training Certificate as soon as possible and will submit to LPA via email.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 6 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(c)
Administration of Child Day Care Licensing
(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have any records for review available at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee stated her records were in another place and will get them as soon as possible. LPA will come back out to review records.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have any records for review available at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee stated records were in another place and get them as soon as possible. LPA will come back out to review.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 7 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have staff records available for review at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will get records together as soon as possible. LPA will come back out to review.
Type B
Section Cited
CCR
102370(k)(1)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility. (1) Documentation shall be available for inspection by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have records available for review at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will get records together as soon as possible. LPA will come back out to review.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 8 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102391(d)
Inspection Authority of the Department
(d) The licensee shall permit the Department to inspect, audit, and copy children's records or other family child care home records upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have records for review available at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will get records togeter as soon as possible. LPA will come out to review.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) Licensee CPR has expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will complete and provide to LPA via email.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 9 of 44


Document Has Been Signed on 12/09/2022 12:48 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: BLACKLOCK, ATCHA
FACILITY NUMBER: 073406612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) Licensee did not have current preventative health practices which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
Licensee will complete as soon as possible and submit to licensee.
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) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 10 of 44