073409126-8-10-2021-02-CC-MGUT-C5RMQB-20210810094828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409126
Report Date: 08/10/2021
Date Signed: 08/10/2021 09:49:07 AM

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:	ALLEN, MELISSA		FACILITY NUMBER:	073409126
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 4	DATE:	08/10/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Melissa Allen		TIME COMPLETED:	10:00 AM

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 08/10/21, at 09:00 AM Licensing Program Analyst (LPA) Melissa Guirit arrived at the home for an unannounced Licensee initiated Case Management inspection. Licensee requested on application to increase capacity from a small family childcare home to a large. During inspection, LPA confirmed the health & safety standards as required by regulations governing family childcare homes were met. Present for this inspection were licensee and 4 preschool-aged day care children. Licensee and LPA toured the on limit areas of the home and the living room that will be added as an on limits area during today's inspection. The facility's operating hours are from 7:30 AM to 5:30 PM. This is a single-story home which consists of 2-bedrooms, 2-bathrooms, office, kitchen, living room, dining room, child care room (sun room), and garage. The on limit areas include the children's bedroom at the end of the hallway, dining room, child care room (sun room), hallway bathroom, and living room. The living room that is now an on limit area has a fire place that is locked to ensure that it is inaccessible by children in care. Off limit areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. The fenced backyard will be used as the outdoor play area. There are age appropriate toys in the home and outside. Per licensee, there are no firearms in the home. LPA did not observe any hazardous materials or toxins accessible to children today. The home has a fully charged 2A10BC fire extinguisher and a pull-down fire alarm system. The home is equipped with working smoke detectors and carbon monoxide detector. There is a working telephone in the home. The applicant’s CPR and First Aid certificate is current and expires on 10/2022. Licensee completed mandated reporter training which expires on 10/2022. Licensee is in compliance with immunization requirements. See 809-C for continuance.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

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: ALLEN, MELISSA	FACILITY NUMBER: 073409126
	VISIT DATE: 08/10/2021

NARRATIVE

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Safety precaution in regards to COVID-19 were discussed and assessment was completed.

The licensee was 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. The applicant was reminded of the responsibility as a mandated reporter.

Incidental Medical Services (IMS) policy was discussed.

Safe Sleep Regulations were discussed and a copy of the Individual Sleep Plan was provided.

There are no deficiencies cited during today's inspection. This report shall remain on file for three years. A copy of this report was provided to the licensee via email due to printer issues. Appeal rights and Notice of Site Visit were also provided to the licensee. Exit interview conducted with licensee.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC809 (FAS) - (06/04)

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