073407944-12-19-2019-02-CC-PPEN-BJZW4H-20191219155735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407944
Report Date: 12/19/2019
Date Signed: 12/19/2019 03:57:43 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:	HARRIS, INGE-LISA		FACILITY NUMBER:	073407944
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	12/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Inge-Lisa Harris		TIME COMPLETED:	04:10 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	Licensing Program Analyst (LPA) Paul Petersen conducted an unannounced random annual site inspection for this facility at 1430. LPA met with licensee, Inge-Lisa Harris, and toured all areas on limits for children in care for a health and safety inspection. Also present at the time of this inspection were six children in care consisting of five preschoolers and one school age child. The facility is within capacity. All adults present are background cleared. The areas on limits for children in care are the living room, the kitchen and dining room area and the hall bathroom. Off limits areas are made inaccessible by closed doors and visual supervision. There is one fireplace which is screened to prevent access. There are age appropriate toys and furnishings which appear free of broken/sharp pieces. Child safety fasteners are in place on cabinets and no hazardous items/toxins are observed to be accessible to children in care. Per licensee there are no firearms stored or present on the premises. The back yard/play area is fully fenced and on limits to children in care with adult supervision present at all times that children are using the area. There are no pieces of high climbing equipment of swings present. There are no pets present. There are no pools, hot tubs or accessible bodies of water present. The facility has a working smoke detector, working carbon monoxide detector and fully charged fire extinguisher. The facility has an application on file for an increase of capacity which is pending fire department clearance. Continued on Page 2*************************************************************************************

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

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: HARRIS, INGE-LISA	FACILITY NUMBER: 073407944
	VISIT DATE: 12/19/2019

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 Sections 102417. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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

LPA reviewed the facility, staff and children's records including parents' rights forms, emergency ID forms and consent form emergency medical treatment. Licensee has current CPR/First Aid certification which expires . LPA reviewed with licensee the current Facility Personnel Report Summary and verified that all adults requiring background clearances are cleared and associated to this facility.

The Safe Sleep Awareness Campaign PIN packet was provided and reviewed. Licensee is encouraged to visit www.ccld.ca.gov for licensing regulations and forms. To sign up for quarterly updates contact: childcareadvocatesprogram@dss.ca.gov.

There were no deficiencies cited during this inspection. A notice of site visit was printed and posted and is to remain posted for a period of 30 days. A copy of this report is to be maintained in the facility records for three years and available for public review.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

LIC809 (FAS) - (06/04)

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