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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623239
Report Date: 08/22/2019
Date Signed: 08/22/2019 04:27:15 PM

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:STITH, LAURENFACILITY NUMBER:
293623239
ADMINISTRATOR:STITH, LAURENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 205-7447
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY:14CENSUS: 2DATE:
08/22/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Lauren StithTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Blake Morillas met with the Licensee, Lauren Stith, for a change of location. Licensee moved from 11456 Alta Sierra Drive in Grass Valley to this location. This is a two story, four bedroom, three bathroom home. A fire clearance has been received and approved.

Licensee owns the home and provided the appropriate forms.

LPA explained about obtaining $300,000 liability insurance. Licensee understands that until a policy is obtained, she must use the affidavit.

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: Upstairs, Master Bed/Bath, Living Room, Kitchen, Laundry Room, Backyard, Garage. 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: 3/2020) and Mandated Reporter Training.

LPA provided and discussed the Safe Sleep in Child Care and Lead Testing brochures (AB 2370).

Continued on LIC 809-C

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

DATE: 08/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019
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: STITH, LAUREN
FACILITY NUMBER: 293623239
VISIT DATE: 08/22/2019
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Continuation of LIC 809

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.

The outdoor area used by children is fenced and age appropriate toys were observed. Licensee understands that 100% supervision is required in any unfenced areas as well as when using the porch.

There is a fire place in the home that is properly screened.

There is a non-functioning decorative water feature in the back yard that is currently empty. Licensee understands that if repaired and in use, the water feature must be fenced in accordance with Title 22 Regulations.

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 today (8-22-2019) 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: 08/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019
LIC809 (FAS) - (06/04)
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