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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623143
Report Date: 06/14/2019
Date Signed: 06/14/2019 10:51:34 AM

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:ALLEN, JENNIFERFACILITY NUMBER:
293623143
ADMINISTRATOR:ALLEN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 913-2088
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 0DATE:
06/14/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer AllenTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Blake Morillas met with the Licensee, Jennifer Allen, for a change of location and increase of capacity from a Small Family Child Care home to a Large Family Child Care home. Licensee moved from 320 Bennett St Apt 15, Grass Valley, to this location. This is a single story, 3 bedroom, 2 bathroom home. There is also an attached 1 bedroom, 1 bathroom apartment to the home.

Licensee Rents the home and provided the appropriate forms. Licensee is in the process of transferring the liability insurance to this address. Licensee understands that until a policy is obtained, she must use the affidavit. The Fire Safety Inspection Clearance has been received and the home has been cleared for up to 14 children.

All adult residents received criminal record clearances. LPA reminded Licensee of the applicable Civil Penalty per person for those adults, including your own children, who have not received fingerprint clearances. LPA advised the Licensee of their responsibility to stay current with the requirements of the Department.

Off-limit areas: Attached Apartment, Basement, Master Closet, and First Bedroom. Licensee understands that children may never enter these off-limit areas.

Licensee has certificates of completion for Preventative Health and Safety training including CPR/First Aid (expires: 2/2021). LPA provided and discussed the Safe Sleep in Child Care and Lead Testing brochures (AB 2370). LPA reviewed the fire drill requirements. Fire extinguisher, carbon monoxide and smoke detectors meet regulation. Hazardous cleaning compounds and medications are stored inaccessible and or out of children reach.

Continued on 809-C
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: ALLEN, JENNIFER
FACILITY NUMBER: 293623143
VISIT DATE: 06/14/2019
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The outdoor area used by children is fenced and age appropriate toys were observed. There is also a fenced deck that will also be used by the children. Licensee understands that 100% supervision is required in any unfenced areas and when children are using the fenced deck.

There is a spa at the home. The spa is covered and locked on all sides. Licensee stated there are no weapons in the home.

Licensee was encouraged to visit the Department website at http://ccld.ca.gov for child care updates, current forms, legislation and regulation information.

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

Effective Monday, 6-17-2019 the facility is licensed to serve a MAX. CAP(WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
LIC809 (FAS) - (06/04)
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