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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408994
Report Date: 04/08/2022
Date Signed: 04/11/2022 03:23:23 PM


Document Has Been Signed on 04/11/2022 03:23 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:FORD, TAMIKAFACILITY NUMBER:
073408994
ADMINISTRATOR:FORD, TAMIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 680-9207
CITY:RICHMONDSTATE: CAZIP CODE:
94801
CAPACITY:14CENSUS: 9DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Tamika FordTIME COMPLETED:
01:54 PM
NARRATIVE
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On Friday, April 8, 2022 Licensing Program Analyst (LPA) Caroline Colson met with Tamika Ford, licensee, and her adult assistant, Sydney Smith for an unannounced random annual inspection at 10:07 AM. Licensee's two teenage children were present. There are 3 infants, 2 preschool children and 3 school age children. The home was toured to conduct a health and safety inspection. Ms. Ford was informed of the new civil assessments of up to $500 per adult for not having cleared fingerprints on file (if needed) before contact with the day care children. The facility's operating hours are Monday - Friday from 5:30 AM to 6:00 PM.

The home is a 1 story home. The home consist of a living room with adjacent dinning area, kitchen, 3 bedrooms, 1 bathroom, Sun room, fenced backyard and unfenced front yard. Ms. Ford states that there are no firearms. The isolation area is an area in the living room. The Off Limits areas are all the bedrooms, hall closet and the fenced backyard. The fireplace and wall heaters are properly screened. The home has a 2A10BC fire extinguisher, smoke detector and carbon monoxide detector. There are two steps that lead to the Sun room. Each child has safe, healthful, comfortable accommodations, furnishings and equipment. Children are being supervised at all times. Fire and Disaster Drills are conducted. Control of Property will be sent to our department by May 9, 2022. Ms. Ford will take the children to the neighborhood park for outdoor play. Before the fenced backyard can be used, there will be a renovation and an inspection will be conducted. Mandated Reporter Training certificate expires on June 16, 2023. Pediatric CPR and First Aid certificates expires on August 21, 2023. There are no pets.

See LIC 809 C for additional information
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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 7


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: FORD, TAMIKA
FACILITY NUMBER: 073408994
VISIT DATE: 04/08/2022
NARRATIVE
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· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.



CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

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 ADA, available at: http://www.ada.gov/childquanda.htm

The attached type B deficiencies are being cited today and must be corrected by the due date.

The attached type A deficiency is being cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

Please See LIC 809 C for Additional Information
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: FORD, TAMIKA
FACILITY NUMBER: 073408994
VISIT DATE: 04/08/2022
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Family Child Care Homes

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.


Safe Sleep

LPA discussed the safe sleep regulations with Tamika Ford and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Karla Sparks-Hunter 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.

Notice of Site Visit

A notice of site visit was given and must remain posted for 30 days.

Exit Interview

Exit interview conducted and report was reviewed with the licensee, Tamika Ford.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2022 03:23 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: FORD, TAMIKA
FACILITY NUMBER: 073408994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having an adult work in the home without a Criminal Record Clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will have the assistant obtain a Criminal Record Clearance before returning back to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 04/11/2022 03:23 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: FORD, TAMIKA
FACILITY NUMBER: 073408994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2022
Plan of Correction
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Licensee will be sent copies of the LIC 995 A for all parents to complete and place in each child's file.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2022
Plan of Correction
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Licensee will be sent a copy of the Consent for Medical Treatment for all parents to complete and place in each child's file.

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) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 04/11/2022 03:23 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: FORD, TAMIKA
FACILITY NUMBER: 073408994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2022
Plan of Correction
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Licensee will complete a roster and send to Oakland Child Care Office.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 infants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2022
Plan of Correction
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Licensee will complete the logs for all infants in care.

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) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 04/11/2022 03:23 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: FORD, TAMIKA
FACILITY NUMBER: 073408994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418


This requirement is not met as evidenced by:
Deficient Practice Statement
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(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
POC Due Date: 05/08/2022
Plan of Correction
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Licensee will request immunization records from all families and complete the California School Immunization Form for each child.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7