313621518-1-3-2020-03-CC-ABLI-BKGTK7-20200103134729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313621518
Report Date: 01/03/2020
Date Signed: 01/03/2020 01:47:34 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:	GRAY, DECEMBER		FACILITY NUMBER:	313621518
ADMINISTRATOR:	GRAY, DECEMBER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 204-9281
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	14	CENSUS: 9	DATE:	01/03/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	December Gray		TIME COMPLETED:	02:00 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 (LPA) Amanda Blesi met with the assistants Olivia and Madison for the purpose of an unannounced Annual inspection. Licensee was not in the facility upon arrival but was called and arrived shortly after. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was no infants and 9 children over age two years old. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the entire upstairs, and garage. 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. LPA observed weapons to be stored and locked separately from ammunition. 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 and both assistants. Mandated Reporter Training (AB 1207) for Licensee was also verified and expires November 2021. This provider is currently providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. 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: 01/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020

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: GRAY, DECEMBER	FACILITY NUMBER: 313621518
	VISIT DATE: 01/03/2020

NARRATIVE

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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 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 child care updates, current forms, legislation and regulation information.

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

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020

LIC809 (FAS) - (06/04)

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