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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 163910611
Report Date: 10/22/2019
Date Signed: 10/23/2019 09:36:46 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:HOLE, ALICE FAMILY CHILD CAREFACILITY NUMBER:
163910611
ADMINISTRATOR:HOLE, ALICEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 816-7787
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY:14CENSUS: 4DATE:
10/22/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Alice HoleTIME COMPLETED:
12:10 PM
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On this date, Licensing Program Analysts (LPAs) Kathy Pacheco and Ruby Ocegueda conducted an unannounced annual/random inspection. LPAs met with Alice Hole, who provided a tour of the home, inside and outside, as shown on the facility sketch. Swimming pool is fenced per regulation. Firearms and ammunition are properly stored. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. Fireplace is in an off-limits room and inaccessible to children. The fire extinguishers, smoke detectors, and carbon monoxide indicator meet Community Care Licensing (CCL) regulations. The home is kept clean and orderly, with heating and ventilation for safety and comfort. Stairs are barricaded when children under age 5 years old are present. Safe toys and play equipment are observed. The back yard play area is currently off-limits to day care children. Licensee understands she must contact CCL for an inspection prior to using the back yard for day care use. There are three dogs, two cats that are kept outside of the home and two guinea pigs inside the home. Licensee understands the liability of pets around day-care children and accepts responsibilities of any action taken by pets. Licensee has a working telephone and the above telephone number was verified. Adequate supervision is being provided during this inspection. Capacity as specified on the license is being maintained. Children’s records contain all emergency information specified by regulation. There are no excluded individuals present at this home. All adults who reside or work in the home have a criminal record clearance or exemption as indicated on LIS 531 – Facility Personnel Report Summary. The Licensee and other personnel as specified have completed training on preventative health practices including pediatric CPR and first aid; Expires: January/2021.

Licensee provided proof of required immunization (Pertussis/Measles/Influenza) and or written declaration was provided. Licensee provided proof of required Mandated Reporter Training; Completion: 3/27/18.

Report continued on page 809-C
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy PachecoTELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HOLE, ALICE FAMILY CHILD CARE
FACILITY NUMBER: 163910611
VISIT DATE: 10/22/2019
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Incidental Medical Services (IMS) policy was discussed. Licensee is aware that an IMS plan is required to be submitted to the Licensing office if they provide any of these services.

LPA provided Licensee with information regarding the California Department of Social Services (CDSS) Provider Information Notices (PINs) communication system; information regarding Safe Sleep Regulations; AB 2370, Chapter 676, Statutes of 2018, requiring child care providers to inform parents and/or guardians with lead safety information, and other important resources and information links offered on the CDSS website.

Business hours are Monday through Friday 5:30 AM to 9:30 PM and other hours as arranged.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations no deficiencies are observed today.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy PachecoTELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
LIC809 (FAS) - (06/04)
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