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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408782
Report Date: 12/17/2019
Date Signed: 12/17/2019 01:08:49 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:SERVICE, MICHELLEFACILITY NUMBER:
073408782
ADMINISTRATOR:SERVICE, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 360-0274
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:14CENSUS: 11DATE:
12/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Service MichelleTIME COMPLETED:
01:30 PM
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3 LPA, Hollie, met with the Licensee for the purpose of a Random Health and Safety Inspection. Present in care today are eleven day care children with three infants and eight toddlers. Also present is the Licensee's husband and three staff , Ms. Monarque, Ms. McSweeney and Ms. Suarez. The entire home is ON LIMITS to children. A There are no bodies of water or fire arms on the premises, per the licensee. The Licensee is present in the home and ensures that children are supervised. The Licensee understands that children are not to be placed in locked cars. The home is orderly with heating and ventilation for safety and comfort. Poisons, detergents, cleaning compounds, medications and other items which could pose a danger to children, are inaccessible during this visit. Fireplaces and open face heaters are screened to prevent access by children. There is a charged 2a10bc fire extinguisher and a working smoke detector as well as a carbon monoxide detector in the home. PLEASE SEE NEXT PAGE FOR CONTINUED REPORT.
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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 4
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: SERVICE, MICHELLE
FACILITY NUMBER: 073408782
VISIT DATE: 12/17/2019
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There are no stairs in the home. The home has toys, play equipment and materials for children. The licensee is aware that when she is temporarily absent from the home, she must ensure that a fingerprint cleared adult is present with current CPR/First Aid and have verification of immunization that includes Measles, Pertussis and Influenza (optional) or provide medical exemption signed by their Physician. The facility is operating within her licensed capacity today. There are comfortable accommodations, furnishings and equipment for children. There is a current roster. The licensee has current CPR/First Aid which expires April 04-20-19.

The licensee understands that all person’s 18 years of age or older, who frequently visits, works or resides in the home, shall be fingerprint cleared/associated to the home and have immunization's, PRIOR to being in the presence of children. LPA reviewed a sampling of children’s records for documentation of Immunization and Notification of Parents Rights. The home conducts and documents fire drills as required. The licensee was informed that parents should shown the Disaster Plan and be informed of the Relocation Sites in case the Family Day Care home has to evacuate.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: SERVICE, MICHELLE
FACILITY NUMBER: 073408782
VISIT DATE: 12/17/2019
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LPA provided Licensee with a printed copy of the A Child Care Provider’s Guide to Safe Sleep/Best Practices documentation and discussed the material related to children under the age of one. The licensee states she understands the concepts and is currently practicing safe sleep with day care children. The licensee has the required immunization's on file.

The back yard continues to be fenced. Children play on moveable play equipment and older children play on the anchored play equipment. The home has no pets.

LPA encouraged the Licensee to review our website at CCLD.CA.GOV to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business. Licensee was informed that she can view CCLD’s website for Provider Information by the PINs.


There are no children that require Incidental Medical Services. The licensee and her husband has completed the Mandated Reporter Training. Licensee was informed on how to submit an IMS Plan of Operation.
PLEASE SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SERVICE, MICHELLE
FACILITY NUMBER: 073408782
VISIT DATE: 12/17/2019
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LICENSEE WAS INFORMED THAT IF THE FACILITY IS ISSUED A DEFICIENCY NOTICE, THE PLAN OF CORRECTION MUST BE CORRECTED BY THE DATE PROVIDED OR A CIVIL PENALTY OF $100 PER DAY WILL BE ASSESSED TO THE FACILITY UNTIL THE DEFICIENCY IS CORRECTED. ADDITIONALLY, A REPEAT VIOLATION OF A DEFICIENCY WILL BE ASSESSED IN THE AMOUNT OF $250 AND $100 PER DAY UNTIL CORRECTED.

As a result of this visit, there are no deficiencies sited today.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4