233009977-9-17-2020-01-CC-MTRH-BTJW56-20200917165837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233009977
Report Date: 09/09/2020
Date Signed: 09/17/2020 04:59:07 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:	HALE, TABITHA FCCH		FACILITY NUMBER:	233009977
ADMINISTRATOR:	HALE, TABITHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 472-1292
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	14	CENSUS: 0	DATE:	09/09/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Tabitha Hale, Applicant		TIME COMPLETED:	04:40 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 pre licensing inspection visit was conducted today by LPA, Mary Trinh. This visit is a "Relocation" as the Licensee moved to another home. Due to Covid19 this visit is done by tele-visit (Zoom). The applicant is requesting a license for a capacity of 14. Services will be provided 7:30 am - 5:15 pm. M-F. The applicant understands that child care must be provided in the "primary" residence of the applicant. The residence is a four bedroom/two bath home. There are two adults and two minors living in the home. Applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. 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. Two bedrooms/ one bathroom are off limits to the children. These areas have been made inaccessible by means of door knob covers. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. No poisons are kept in the home. The applicant reports there is a gun in the home and is kept per Title 22 regulations. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2A10BC. The fireplace is an electric heater that will not be used. The children will use the back yard as the outdoor play area. The backyard is completely fenced therefore, the applicant understands that constant supervision must be provided while children are outside. There is no trampoline on the premises. There is no pool. There is a hot tub that is covered and locked. (Continued...)

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary Trinh	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

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: HALE, TABITHA FCCH	FACILITY NUMBER: 233009977
	VISIT DATE: 09/09/2020

NARRATIVE

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Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property or landlord notification/consent is on file. 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 on Pediatric CPR and First Aid. 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. 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 during the hours of operation in those areas where children are present.
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/
Megan's Law web site was provided (http://www.meganslaw.ca.gov). The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 http://www.ada.gov/childqanda.htm.
This report, as well as the Safe Sleep Concepts and Effects of Lead Exposure brochure were reviewed and discussed with the applicant. All licensing reports are public information and must be made available upon request for at least three years.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
The Fire Marshall from Redwood Fire Department approved the fire clearance on 08/28/2020.
This report will be emailed and mailed to Tabitha Hale to obtain original signature.
The facility is ready for licensure as of 09/09/2020.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary Trinh	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC809 (FAS) - (06/04)

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