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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274412915
Report Date: 06/30/2022
Date Signed: 06/30/2022 03:49:17 PM


Document Has Been Signed on 06/30/2022 03:49 PM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CLANCEY, CAROLINEFACILITY NUMBER:
274412915
ADMINISTRATOR:CLANCEY, CAROLINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 540-8878
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:14CENSUS: 0DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Caroline ClanceyTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Joe Macias conducted an unannounced Required - 1 Year Inspection (care tool). LPA was greeted and granted entrance by the Licensee Caroline Clancey. The purpose of today’s inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Todays census is 0, the Licensee is currently on summer break. The Licensee is the only adult who reside in the home. The day care hours of operation are Monday - Friday, 9am - 3pm. The Licensee's CPR and First Aid are current and expire September 2023. The Licensee's fees are current.

LPA toured the indoor and outdoor areas of the home during today's visit. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's visit. The last fire disaster drill was conducted on March 2, 2022. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the children in care. The home is orderly, and safe for the day care children. The LPA observed a securely gated wall heater in the home. Off limit areas of the home: all bedrooms, laundry room, and the Licensee's studio.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke, and carbon monoxide detectors, and no bodies of water. The Licensee states that she does not have weapons in the home. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children. Licensee states that she does not administer medications at this time. LPA reviewed the RAST procedure with the Licensee.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours to ensure that the children are safe and supervised at all times. The Licensee understands the current capacity options and she understands that she cannot have more than 14 children in the home at any time, with a qualified assistant present. LPA provided the Licensee with the ratio/capacity chart for his reference. The Licensee states that she does not transport children; however she understands that children cannot be left in parked vehicles unattended any time.

LPA observed staff immunization records on file.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CLANCEY, CAROLINE
FACILITY NUMBER: 274412915
VISIT DATE: 06/30/2022
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LPA discussed the safe sleep regulations with the License and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

A review of staff records on June 30, 2022 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 Caroline Clancey 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

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



The Licensee has completed the Mandated Reporter Training.

No deficiencies cited. Exit interview conducted and report was reviewed with the Licensee Caroline Clancey.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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