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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290312405
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:44:04 PM


Document Has Been Signed on 10/25/2022 12:44 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:TATE, CAROLYNFACILITY NUMBER:
290312405
ADMINISTRATOR:TATE, CAROLYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 272-2513
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 12DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Carolyn TateTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPAs) Amanda Blesi Soleil Marx met with Licensee, Carolyn Tate, for the purpose of an unannounced required 1-year inspection. The licensee's husband and assistant were also present during the inspection. At 11:50am. LPA observed a total census of 12 children including 3 infant children.

At 11:55 a.m., Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include all master bathroom, rear hall bathroom, and laundry room. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home . Toxic and hazardous items are inaccessible to children. No Fireplace in the home. There are no stairs in the home. Outdoor play space is fenced.

Licensee 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.

LPA reviewed five children’s files. A current roster is being maintained and fire and disaster drills are documented. Current CPR and First Aid certification was verified and expires 3/2024. (Report continues LIC809-C)
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: TATE, CAROLYN
FACILITY NUMBER: 290312405
VISIT DATE: 10/25/2022
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LPA observed two play yards at the facility. Play yards were free of loose objects. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

LPA discussed the safe sleep regulations with licensee 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 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

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. 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

No deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the licensee Carolyn Tate. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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