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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623631
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:02:05 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:HAUBER, DEVAFACILITY NUMBER:
293623631
ADMINISTRATOR:HAUBER, DEVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(917) 627-0103
CITY:NEVADA CITYSTATE: CAZIP CODE:
95959
CAPACITY:14CENSUS: 0DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Deva Hauber - LicenseeTIME COMPLETED:
03:20 PM
NARRATIVE
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On Thursday, September 16th, 2021, at 1:54pm, Licensing Program Analyst (LPA) Blake Morillas met with the Licensee, Deva Hauber, for the purpose of an unannounced Annual Required inspection. All individuals subject to criminal background review have obtained a criminal record clearance. No children were present at the time of the visit.

Operating hours are 8:30am to 1:00pm, Monday through Thursday. The facility closes for the summer.

At 1:58pm, LPA initiated a health and safety inspection of all areas accessible to children. Off-limits areas include the all of the Downstairs of the Home, the Outdoor Shed, and the Detached Cabin. Licensee acknowledged that children may never enter these off-limit areas.

LPA observed a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors.

Licensee stated there are no weapons in the home. Toxic and hazardous items (detergents, cleaning compounds, medications, sharp utensils, items that could pose a danger to children in care) are properly stored and inaccessible to children.

There is no fireplace in the area accessible to children in care. There are stairs in the home which are properly barricaded. Safe toys and play equipment are observed. The outdoor play space is fenced. The Licensee understands that in unfenced outdoor areas, 100% supervision of children is required.

There are no bodies of water on the premises.

*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: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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: HAUBER, DEVA
FACILITY NUMBER: 293623631
VISIT DATE: 09/16/2021
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*Continuation of LIC 809

At 2:10pm, LPA began to review Children’s files and other documentation. A current roster is being maintained.

Incidental Medical Services (IMS) policy was discussed. 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 for TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the Americans with Disabilities Act, available at: http://www.ada.gov/childqanda.htm

LPA provided and discussed the Safe Sleep in Child Care regulations as well as current Covid-19 guidelines.

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



In the areas that were evaluated, there were no deficiencies at this time.

At 2:57pm, LPA reviewed and discussed this facility evaluation report with the Licensee.



LPA provided a Notice of Site Visit and the Licensee acknowledges that this notice shall remain posted for 30 days for parental review.

The Licensee was provided a copy of the Appeal Rights (LIC9058) and the Licensee's signature on this form acknowledges receipt of these rights as well as the report.

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

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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