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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620770
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:46:43 PM

Document Has Been Signed on 11/05/2021 02:46 PM - It Cannot Be Edited

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:JOHNSON, MICHELLEFACILITY NUMBER:
313620770
ADMINISTRATOR:JOHNSON, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 690-9846
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle JohnsonTIME COMPLETED:
03:00 PM
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On November 5th, 2021, Licensing PrograDocument Link Iconm Analysts (LPAs) Jeremey McClain and Josiah Gathing met with Licensee Michelle Johnson for an unannounced annual inspection.

LPA observed a census of 10 children, which included four infants and four preschool age children, and two school age. Licensee stated there aren’t new residents in the home. Licensee’s assistant Madeline Smith was present during the inspection. All adult residents have criminal record clearances.

LPA toured areas of the home accessible to the children. The off-limit areas of the home were inaccessible.

LPA observed current CPR/First Aid certificate which expires 02/21/2023. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA observed that licensee has current completion of AB1207 Mandated Reporter training, which expires 02/21/2023. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years. LPA advised licensee that all assistants must also complete this training.

LPA reviewed children's records for completeness, as well as the client roster. LPA observed records of immunizations for MMR, Pertussis, and influenza/ influenza declination.

During the interior and exterior inspection:
LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach.
LPA observed a working telephone in the home.
Licensee stated that there are no weapons in the home.
LPA observed a fire extinguisher, as well as functioning carbon monoxide and smoke detectors. LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months.
Equipment and furnishings in areas where children are active appeared to be safe and in working order.
LPA did not observe standing bodies of water during today’s inspection.
REPORT CONTINUED ON THE FOLLOWING PAGE.
Keven Peters
Jeremey McClain
DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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: JOHNSON, MICHELLE
FACILITY NUMBER: 313620770
VISIT DATE: 11/05/2021
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This facility does not currently provide Incidental Medical Services- IMS. 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


LPA discussed recent changes in licensing requirements, Safe Sleep Regulations Concepts and provided licensee.

No deficiencies were observed during today’s inspection.



This report was reviewed with licensee, and an exit interview was conducted.

A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISOR'S NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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