173010131-11-4-2021-01-CC-GOUE-C8FR4Q-20211104124155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 173010131
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:42:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	PISENO, STEPHANIE FCCH		FACILITY NUMBER:	173010131
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	11/04/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Stephanie Piseno		TIME COMPLETED:	12:45 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 prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Glenn Ouye. The applicant is requesting a license for a capacity of 8 children. The applicant is qualified to operate a large FCCH based on her work experience as an preschool teacher. Services will be available Monday - Friday, 6:00 AM - 5:30 PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a four bedroom/two and bathroom, dual level home. There are two adults living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. The floor and yard plans are verified. The children will have access to the first floor kitchen, living room area and downstairs bathroom. The "off limits" areas include the home's entire second floor and all its bedrooms, the downstairs laundry area, the downstairs bedrooms. These areas will be made inaccessible by door knob slip covers and child gates. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. There were no firearms and ammunition in the home at the time of this inspection. Poisons are to stored in a locked setting. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies will be maintained at the facility. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector and carbon monoxide detector. The fire extinguisher is currently a 1A10BC. The applicant must obtain a fire extinguisher rated at least 2-A 10:BC. The home's fireplace and stairs are barricaded. The home's backyard is fully fenced and will be used for childcare. The side yard on the right side of the home is off-limits and fenced off. There is no spa, pool, pond, or fountain on the premises. Continued on LIC 809-C

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn Ouye	TELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PISENO, STEPHANIE FCCH	FACILITY NUMBER: 173010131
	VISIT DATE: 11/04/2021

NARRATIVE

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Incidental Medical Service (IMS) regulations were reviewed with the applicant. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department.

Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. The applicant is a homeowner and proof of ownership has been received. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in any area where child care is provided. The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. Infant safe sleep regulations and the effects of lead exposure were discussed with the applicant. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

When the applicant can provide proof of purchase of a fire extinguisher rated at 2A10BC, the home will be approved for licensure as a small FCCH.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn Ouye	TELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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