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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103911169
Report Date: 03/09/2020
Date Signed: 03/09/2020 10:40:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:WILBORN, PATRICE & MASSEY, VALLIE FCCFACILITY NUMBER:
103911169
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/09/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vallie Massey & Patrice WilbornTIME COMPLETED:
11:00 AM
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On March 9, 2020, Licensing Program Analyst (LPA), Norma Lomeli met with Applicants, Vallie Massey and Patrice Wilborn for a pre-licensing inspection. Applicants are the only persons who reside in the home. Background clearances are discussed and LIS 531 is signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance.
Fire clearance was granted on February 10, 2020.

Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed:
  • Fire clearance was received on February 18, 2020. Fire alarm is located on the wall as you enter the home’s main entry way.
  • This is a two story, three bedrooms and two and a half bathrooms home and upstairs area will be off-limits to the day-care children. There is a gate at the bottom of the stairs making upstairs area inaccessible. Care and supervision will be provided in living room, dining room, kitchen and downstairs bathroom.
  • LPA observed safe toys and books for the children. There is a diaper changing table. Children will nap on cots. Infants will nap in play yards. Applicants understand that they will supervise children at all times.
  • Facility has 2A10BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place.
  • Applicants Pediatric CPR and First Aid certification was completed through American Red Cross and expires on 4/21/2020.
(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: WILBORN, PATRICE & MASSEY, VALLIE FCC
FACILITY NUMBER: 103911169
VISIT DATE: 03/09/2020
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  • Preventative Health and Safety class was completed by applicants on February 15, 2020.
  • Knives are stored in a top kitchen cabinet inaccessible to day care children. Medications are stored in an upstairs bedroom inaccessible to the day care children.
  • Advised applicants fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
  • Applicants are advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
  • There are no bodies of water in the home or premises.
  • Applicants state that there are no pets in the home or on the premises.
  • Applicants state that there are no weapons, firearms, ammunition or poisons in the home or premises.
  • Applicants are reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
  • Applicants are advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Applicants state that the home is smoke-free.
  • Applicants state that they will not be transporting day care children. Applicants understands that they must have proper restraints and/or car seats for all the children under their care when transporting children.
  • Fenced backyard has a cemented and sodded area for the day children to play.
  • SB 792 immunizations verified and on file.
  • Applicants completed the Mandated Reporter Training on May 24, 2018
  • LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given to applicant.
  • 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.

(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: WILBORN, PATRICE & MASSEY, VALLIE FCC
FACILITY NUMBER: 103911169
VISIT DATE: 03/09/2020
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Required postings, forms packet, which included Parent Notification Requirement and LIC9224 were provided and discussed in detail. Applicants are advised that they may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. They are also reminded that it is their responsibility to read the regulations periodically. Applicants states they will operate their day care Monday through Friday from 7:00 AM to 5:30 PM and as arranged. No overnight care will be provided.

Licensure as a Large Family Day Care Home capacity of 14 children ages under 18 years will be recommended effective March 10, 2020.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3