093613009-11-8-2019-03-CC-SDLA-BHQPEU-20191108101544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093613009
Report Date: 11/08/2019
Date Signed: 11/08/2019 10:15:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	BUCKMASTER, KIMBERLY		FACILITY NUMBER:	093613009
ADMINISTRATOR:	BUCKMASTER, KIMBERLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 798-9961
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	14	CENSUS: 12	DATE:	11/08/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kimberly Buckmaster		TIME COMPLETED:	10:30 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	Licensing Program Analysts (LPAs) Seychelle De Luca and Michelle Pascual met with Licensee Kimberly Buckmaster for the purpose of an unannounced annual random inspection. Licensee's husband was also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. LPAs observed 12 preschool children in care. Facility hours are Monday through Friday from 8:30 AM to 12:00 PM. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the entire third floor, main level bedroom, laundry room, and garage. LPAs observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. Toxic and hazardous items are inaccessible to children. Safety latches are in use on some kitchen cabinets and bathroom cabinets and drawers. Licensee understands that she must ensure the safety latches are not broken. The fireplace and stairs are appropriately barricaded to prevent access by children and outdoor play space is fenced. The hot tub in the backyard is covered, but three of the four locks on the corners of the cover are broken. LPAs were able to lift the cover over four inches and the hot tub is full of water. 12 children’s files were reviewed. LPAs observed immunization records and signed Family Child Care Home Notification of Parents' Rights in children's files. A current roster is being maintained and fire and disaster drills are documented. Licensee's and Licensee's husbands immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires 7/17/2020. Report continues on 809-C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De Luca	TELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BUCKMASTER, KIMBERLY	FACILITY NUMBER: 093613009
	VISIT DATE: 11/08/2019

NARRATIVE

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This provider is currently not providing IMS services to children in care. 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.

LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form.

A Title 22 deficiency is cited on the subsequent pages of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days 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. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by Licensee. LIC 9224 and Appeal Rights were provided.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De Luca	TELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BUCKMASTER, KIMBERLY	FACILITY NUMBER: 093613009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/12/2019 Section Cited	1 2 3 4 5 6 7	Operation of Family Child Care Home All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement has not been met as evidenced by LPAs observing the hot tub in
	8 9 10 11 12 13 14	the backyard is covered, but three of the four locks on the corners of the cover are broken. LPAs were able to lift the cover over four inches and the hot tub is full of water. This poses an immediate health and safety concern to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De Luca	TELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

LIC809 (FAS) - (06/04)

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