125406793-8-20-2019-13-CC-JSNW-BF8RG9-20190820130022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 125406793
Report Date: 08/20/2019
Date Signed: 08/20/2019 01:00:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	BOUTRIS, DIANE FAMILY CHILD CARE HOME		FACILITY NUMBER:	125406793
ADMINISTRATOR:	BOUTRIS, DIANE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 599-5683
CITY:	EUREKA	STATE: CA	ZIP CODE:	95501
CAPACITY:	14	CENSUS:	DATE:	08/20/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Daine Boutris		TIME COMPLETED:	01:00 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	A Annual inspection was made to the facility by Licensing Program Analyst (LPA), Snow. A review of staff records on 8/20/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently 2 adults living in the home. During today’s inspection the home and grounds were toured. The licensee and assistant were supervising 10 children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 6:30am-6pm Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the upstairs and laundry room and they were made inaccessible by gate and lock respectively. The home was clean and orderly, and was at a comfortable indoor temperature of 77. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 10/21/19. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Poisons are locked in the laundry room.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: BOUTRIS, DIANE FAMILY CHILD CARE HOME	FACILITY NUMBER: 125406793
	VISIT DATE: 08/20/2019

NARRATIVE

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The staircase is barricaded with a gate. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and none were observed during today's inspection. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.
Five children's records were reviewed at 12:30pm; required emergency information was observed to be on file. The licensee is providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

LIC809 (FAS) - (06/04)

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