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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313659
Report Date: 08/26/2019
Date Signed: 08/26/2019 10:39:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CALKINS, LAURA & MICHAELFACILITY NUMBER:
304313659
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
08/26/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Laura & Michael CalkinsTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Dean Valencia conducted an announced Pre-Licensing inspection of the home on today's date, in response to a change of location application. A review of fingerprint clearance records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 3 adults living in the home.

The LPA toured the home with the applicants. The facility with operating hours of Monday through Friday 6AM to 6PM. The facility is a two story family home with 3 bedrooms and 3 bathrooms. The home is clean, orderly, and at a comfortable temperature. There is no fireplace in the home. Off limits areas are: all upstairs and garage. Applicant has placed a baby gate at bottom of the stairs and child proof door handles; ensuring areas are inaccessible to the children in care. The applicant acknowledged the children may not enter the off-limit areas. The children will play in the backyard, and it is completely fenced/walled and free form hazards. Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. Applicant stated poisons/hazardous items are not kept on the premises, and none were observed during a tour of the home. Applicant understands that cleaning solutions/chemicals must be made inaccessible to children at all times and poisonous items must be key/combo locked at all times. There are age appropriate toys and napping equipment on the premises for the potential ages served. There are no bodies of water on the premises. The applicant stated that there are no firearms on the premises. LPA advised applicant that anytime firearms are present in the home, they must be locked and stored separately from the ammunition, at all times. Fire extinguisher (2A:10BC) observed to be fully charged, a smoke detector and carbon monoxide detector were present and were functioning during today's inspection. Applicant understands the home is to be free from smoking at all times. Applicant understands children are never to be left in a vehicle or unsupervised. LPA reviewed the applicant's 16 hours Preventative Health, and Pediatric CPR/First Aid certification expires 6/2021. Current proof of immunization records for pertussis, measles, and influenza were verified and are on file. (continued on LIC809C)

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALKINS, LAURA & MICHAEL
FACILITY NUMBER: 304313659
VISIT DATE: 08/26/2019
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Property Owner/Landlord Notification form LIC9151 is on file, although the LIC9149 is not on file and applicant understands that they are limited to no more than 6 children, without this form signed. The LPA advised the applicant to contact licensing for any changes of off limit areas, operation hours or change in phone number. The following were discussed: Adults (18+) living or working in the home must be fingerprint cleared prior to being present in the facility. If adult is fingerprint cleared and associated to another facility, licensee must complete a Criminal Record Clearance or Exemption Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) and fax to (714)703-2831. LPA reviewed Unusual Incident Report form and advised the applicant to contact Licensing office within 24 hours by phone or fax and complete the Unusual Incident Report (LIC 624B) within 7 days. LPA reviewed with the applicant: Title 22 regulations, requirements of disaster drills (documented every 6 months), LIC 311D, posting requirements, children’s records, facility/staff records, mandated suspected child abuse and injury/death reporting, parent's rights, and children's personal rights. A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Safe Sleep Regulation, and a pamphlet of Effects of Lead Exposure were discussed and provided to the applicant. AB 2084 (Nutritious Beverages) was discussed and is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. The applicant was also informed to visit the http://ccld.ca.gov website for Quarterly Updates, and was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov 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 licensing office within 30 days of providing IMS. The plan should describe the facility’s policies and procedures that ensure the proper safeguards are in place. 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 applicant was provided a copy of their appeal rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. First level appeal is to Regional manager, address is above on the report. The applicant was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This facility meets licensing requirements on this date and a license for a small family child care home will be issued pending a final review. An exit interview conducted where the report was discussed and provided to the applicant.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2019
LIC809 (FAS) - (06/04)
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