313620931-11-21-2019-03-CC-ABLI-BJ5UQF-20191121144703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313620931
Report Date: 11/21/2019
Date Signed: 11/21/2019 02:47:09 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:	JOHNSON, SHANNON		FACILITY NUMBER:	313620931
ADMINISTRATOR:	JOHNSON, SHANNON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 440-6620
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	14	CENSUS: 11	DATE:	11/21/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Shannon Johnson		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Amanda Blesi and Leah Tabtom met with Destiny Fike and Austin Johnson for an unannounced random inspection. Licensee was not present today. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was 11 children ages 6, 11, 2, 3, 5 months, 3, 3, 4, 1, 9 months, 2 years. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include 2 bathrooms upstairs, kitchen and garage. LPA is requesting that licensee send in an updated Facility Sketch LIC 999 to update the off limit areas. LPA observed a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors. Assistant 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. Stairs were barricaded. Safe toys and play equipment are observed. The outdoor play space is fenced. The backyard is fenced and gated. There are no bodies of water observed. Some children’s files were reviewed. A current roster is being maintained. Licensee fire and disaster drills are conducted and documented. CPR and first aid training were verified to be current for licensee. Mandated Reporter Training (AB 1207) for Licensee/Assistant was verified. This provider is currently providing IMS services to children in care. 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.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: JOHNSON, SHANNON	FACILITY NUMBER: 313620931
	VISIT DATE: 11/21/2019

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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 provided and discussed the Lead Testing brochure (AB 2370) and updated Blue Immunization Cards (CDPH 286)

LPA reviewed and discussed this facility evaluation report with the assistant Destiny. LPA provided a Notice of Site Visit and Destiny acknowledges that this notice should remain posted for 30 days for parental review.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiencies are cited during today's inspection. Appeal rights provided.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

LIC809 (FAS) - (06/04)

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