173008469-7-22-2022-01-CC-SPHG-CGKPNW-20220722112837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 173008469
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:28:49 AM

Document Has Been Signed on 07/22/2022 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	NOBLE, KEELY FCCH		FACILITY NUMBER:	173008469
ADMINISTRATOR:	NOBLE, KEELY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 349-4438
CITY:	UPPER LAKE	STATE: CA	ZIP CODE:	95485
CAPACITY:	14	CENSUS: 8	DATE:	07/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Keely Noble		TIME COMPLETED:	11:35 AM

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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Sebastian Phouthavong. LPA met with Licensee, Noble, Keely. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. There are currently two adults living in the home.

During the inspection the home was toured inside and outside. The licensee and assistant were supervising eight children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday - Friday 7:30am - 5:30pm. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the bottom floor of the home and play yard area. The off-limits areas of the home are the upstairs and garage made inaccessible by door locks, plastic doorknob covers and/or child gates. The home appears to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee's pediatric CPR and First Aid certifications were reviewed and expire on 10/2023. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated that no poisons are stored in the home and none were observed during today's inspection. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 2/2022. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection.

Continued on LIC 809-C

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian Phouthavong	TELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NOBLE, KEELY FCCH	FACILITY NUMBER: 173008469
	VISIT DATE: 07/22/2022

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The home's yard is fully fenced. There were no pools or other bodies of water observed. Five children's records were reviewed at 10:00AM. Facility and personnel files were reviewed and will be updated. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Keely Noble

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

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian Phouthavong	TELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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