073408845-5-26-2021-02-CC-CACA-C3DT5M-20210526142546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408845
Report Date: 05/26/2021
Date Signed: 05/26/2021 02:25:51 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:	BRECHEISEN, SHANNON		FACILITY NUMBER:	073408845
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/26/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Shannon Brecheisen		TIME COMPLETED:	02:40 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) Cherie Acosta met with licensee for an unannounced Case Management/Increase in Capacity inspection. Present during the inspection was the licensee and her finger print cleared husband. There were no children in care during the inspection. Licensee is not currently operating. An approved fire clearance dated 3/19/21 has been received. Fire clearance indicates that the garage and second floor of the home are off limits to children. Licensee states that the hours of operation will be 8:30am to 11:30am Tuesday through Thursday. The entire home was toured for a Health and Safety Inspection. This is a two story home. The first floor consists of a living room, family room, kitchen, bedroom, bathroom, and garage. The second floor consist of three bedrooms, office, two bathrooms, laundry room and a loft. The on limits area used for child care are the living room, family room, kitchen and first floor bathroom. The remainder of the home is off limits to children. Off limits area is made inaccessible by closed and/or locked doors and visual supervision The fenced backyard is used as the outdoor play area. There are age appropriate toys in the home. There are no pools, hot tubs or any other similar bodies of water at this home. There are no firearms in the home as stated by the licensee. LPA did not observe any hazardous materials or toxins accessible to children today. The home is equipped with a working smoke detector and carbon monoxide detector. There is a working telephone in the home. The home has a fully charged 3A40BC fire extinguisher. The home has a gas fireplace that is screened. The fireplace is not used during child care hours as stated by the licensee. The stairs are gated. Licensee has current CPR/First Aid which expires 04/23. Licensee completed mandated reporter training 4/5/21. Licensee is in compliance with required immunizations. Files were reviewed. Safe sleep information was provided and discussed with licensee. Safety precaution in regards to COVID-19 were discussed with licensee.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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: BRECHEISEN, SHANNON	FACILITY NUMBER: 073408845
	VISIT DATE: 05/26/2021

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Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov

The increase in capacity is approved today.

Exit interview was conducted with Shannon Brecheisen. Appeal rights were provided.
Notice of site visit was provided and must be posted for 30 days.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC809 (FAS) - (06/04)

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