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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313611330
Report Date: 06/10/2021
Date Signed: 06/10/2021 12:35:36 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:NELSON, ELLENFACILITY NUMBER:
313611330
ADMINISTRATOR:NELSON, ELLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 626-9570
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:14CENSUS: 10DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nelson, EllenTIME COMPLETED:
12:45 PM
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At 12:00pm, Licensing Program Analyst (LPA) Amanda Blesi met with the Licensee, Ellen Nelson, for the purpose of an unannounced Annual inspection. The Licensee's assistant, Sydney Johnson, and spouse were also present upon arrival. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was 2 infants over 12 months and 8 preschool children.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the Master bedroom and hall bedrooms. Licensee acknowledged that children may never enter these off-limit areas. LPA observed a working phone and fire extinguisher. The smoke detector and carbon monoxide detector were tested and observed to be functioning. 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. The fireplace in the home is appropriately barricaded to prevent access by children. There are no stairs in the home. Safe toys and play equipment are observed. The outdoor play space is fenced. There are no bodies of water observed. Five children’s files were reviewed for emergency information per KIT #1. CPR and first aid training were verified and expire 2023.
REPORT IS CONTINUED ON THE FOLLOWING PAGE LIC 809-C
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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: NELSON, ELLEN
FACILITY NUMBER: 313611330
VISIT DATE: 06/10/2021
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Incidental Medical Services (IMS) policy was discussed. 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.
LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the Licensee can request to be added to the distribution list to receive Quarterly Updates.

LPA observed proof that licensee and staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com. Licensee mandated reporter certificate expires on 2/28/2021. Licensee was advised the Mandated Reporter Training (AB1207) shall be renewed every two years.


LPA reviewed and discussed this facility evaluation report with the Licensee and a copy of this report was provided to licensee. LPA provided a Notice of Site Visit and the Licensee acknowledges that this notice should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at http://ccld.ca.gov for childcare updates, current forms, legislation and regulation information.

Appeal Rights were provided.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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