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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185403612
Report Date: 09/11/2019
Date Signed: 09/11/2019 10:48:41 AM

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:SALEM, DOROTHY FAMILY CHILD CARE HOMEFACILITY NUMBER:
185403612
ADMINISTRATOR:SALEM, DOROTHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 253-3317
CITY:JANESVILLESTATE: CAZIP CODE:
96114
CAPACITY:14CENSUS: 10DATE:
09/11/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dorothy SalemTIME COMPLETED:
10:55 AM
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An increased monitoring inspection was made to the facility by Licensing Program Analysts (LPAs), Chris Krogstad and Emilia Grisak. A review of personnel report on 9/10/19 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 is currently three adults living in the home. An informal conference was held with the licensee on 10/18/18 regarding an absence of supervision incident.

During today’s inspection the home and grounds were toured. The licensee, with her adult assistant, were supervising ten children, to include 3 infants and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:30am to 6pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits lower level and upstairs master bedroom were made inaccessible by a gate at the stairway and a door knob cover. The home was clean and orderly. 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 11/2020. 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 detached garage. 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/or other dangerous weapons in the home, 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. Ten children's records were reviewed at 10:02am; liability insurance affidavits were missing. The licensee stated she does not carry child care insurance. Immunization records were not transferred onto the California Immunization Record as required. The licensee is not 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.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Christen KrogstadTELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
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: SALEM, DOROTHY FAMILY CHILD CARE HOME
FACILITY NUMBER: 185403612
VISIT DATE: 09/11/2019
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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: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Christen KrogstadTELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
LIC809 (FAS) - (06/04)
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