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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 223911233
Report Date: 04/08/2020
Date Signed: 04/08/2020 12:41:25 PM

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:HENDERSON, SHANNON FAMILY CHILD CAREFACILITY NUMBER:
223911233
ADMINISTRATOR:HENDERSON, SHANNONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 617-9767
CITY:CATHEYS VALLEYSTATE: CAZIP CODE:
95306
CAPACITY:14CENSUS: 0DATE:
04/08/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shannon HendersonTIME COMPLETED:
01:00 PM
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Prior to today's inspection, LPA telephoned call applicant and conducted the COVID-19 Emergency Response Tele-Inspection Screening Process. On April 8, 2020, Licensing Program Analyst (LPA), Norma Lomeli met with Applicant, Shannon Henderson for a pre-licensing/ change of location inspection. Applicant, and her two minor children reside in the home. Verified Applicant Assistant’s, Briana Shaw CPR and First Aid was completed through American Heart Association and expires on 10/13/2020. Applicant's CPR and First Aid certification expired in February 2020. Applicant states that due to Covid-19, applicant has not been able to register for a CPR/First Aid course. Background clearances are discussed and LIS 531 is signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance. Fire clearance was granted on April 3, 2020.

Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed:
  • Fire clearance was received on April 3, 2020. Applicant states that the fire inspector did not require for her to install a fire alarm.
  • This is a single story, three bedroom and two bathrooms home and children will have access to the kitchen, living room, day care room, bedroom #1, bedroom #2 and hallway bathroom. Off-limits rooms are made inaccessible by use of a lock.
  • There is a wood stove fireplace in the day care room that is fenced with black iron fence. Applicant states it will not be used during day-care hours.
  • LPA observed children size furniture, safe toys, and books for the children. LPA observed a diaper changing table. A flat screen television mounted onto the wall. Children will nap in living room. Infants will nap in a crib. Applicant understands she is to supervise children at all times.
(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: HENDERSON, SHANNON FAMILY CHILD CARE
FACILITY NUMBER: 223911233
VISIT DATE: 04/08/2020
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  • Facility has 3A40BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place.
  • Knives are stored in magnetic knives board that is attached to the kitchen wall. Medications are stored inside a top kitchen cabinet.
  • Advised applicant fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
  • Applicant is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
  • There are no bodies of water in the home or premises.
  • There are three dogs that are kept indoors. There are two Guinea pigs that are kept in a cage in bedroom #1.
    Applicant is advised it is her responsibility to ensure the safety of children in care at all times from the pets.
  • Applicant states there are no firearms, ammunition or poisons in the home or premises.
  • Applicant is reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
  • Applicant is advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Applicant states the home is smoke-free.
  • Applicant states she will be transporting day care children. Applicant understands that she must have proper restraints and/or car seats for all the children under her care when transporting children.
  • Fenced backyard has a four foot geometric climbing play structure, two swing sets with a slide, an individual swing/seat set, a see saw, and other safe toys for the children.
  • SB 792 immunizations verified and on file.
  • Applicant completed the Mandated Reporter Training on March 1, 2018. Applicant and Applicant Assistant will complete the Mandated Reporter Training. Applicant understands that her assistant cannot provide care and supervision to day care children until she completes the Mandated Reporter Training.
(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HENDERSON, SHANNON FAMILY CHILD CARE
FACILITY NUMBER: 223911233
VISIT DATE: 04/08/2020
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  • LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given to applicant.
  • 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.

Required postings, forms packet, which included Parent Notification Requirement and LIC9224 were provided and discussed in detail. Applicant is advised that she may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. She is also reminded that it is her responsibility to read the regulations periodically. Applicant states she will operate her day care Monday through Friday from 7:00 AM to 5:00 PM and as arranged. No overnight care will be provided.

Applicant is advised the following items must be corrected and documentation must be sent to CCL before the front fenced yard can be accessible to the day care children. Applicant will provide documentation to CCL of the following corrections within the next 30 days to avoid possible withdraw.


  • Applicant will anchor to the ground three swing set structures that are located in the fenced front yard. Applicant understands that the front yard will be inaccessible to the day care children.
  • Applicant and Applicant's Assistant will complete the Mandated Reporter Training.

Provisional License for a Large Family Day Care Home capacity of 14 children ages under 18 years will be issued for 180 days, pending receipt of the CPR First Aid certification and Preventive Health and Safety Training certification for applicant. Provisional license will be effective April 9, 2020.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2020
LIC809 (FAS) - (06/04)
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