073409149-11-12-2021-02-CC-THAR-C8Q2LU-20211112163007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409149
Report Date: 11/12/2021
Date Signed: 11/12/2021 04:30:19 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:	PAYTON, MICHELLE		FACILITY NUMBER:	073409149
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	11/12/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	MICHELLE PAYTON		TIME COMPLETED:	04:45 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

3:00PM, Licensing Program Analyst Tasha Alexander met with licensee Michelle Payton for an unannounced INCREASE OF CAPACITY inspection. Present for the inspection were licensee and 6 children in care consisting of 3 infants and 3 preschoolers. LPA toured the facility and backyard for a health and safety inspection. The children's files was not reviewed today. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke detector and working carbon monoxide detector. There is a working telephone in the home. Per applicant there are no fire arms located on the premises. There are no swimming pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children. Licensee has current CPR and 1st Aid training which, expires 2/22/22 respectively. The off limits areas will be 3 of the bedrooms which includes the master bathroom/bath, laundry room, garage and left side of backyard. The "on limits" areas will be the 1st bedroom (infant room) adjacent to the front door, dinning room, hall bathroom next to the infant room and backyard. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
A review of staff records on 11/10/21 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Today licensee has immunization records in file and all are up to date.

The newly implemented mandatory mandated reporter training course was also discussed today. Certificate is up to date.

CONTINUED ON 809-C

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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 2

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: PAYTON, MICHELLE	FACILITY NUMBER: 073409149
	VISIT DATE: 11/12/2021

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
26
27
28
29
30
31
32

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

As a result of this visit, there are no deficiencies cited today. This report must be available for public review for 3 years. An exit interview was conducted. A copy of this report has been emailed to licensee.

THIS HOME WILL BE LICENSED FOR A LARGE FAMILY CHILD CARE HOME EFFECTIVE TODAY 11/12/21.

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2