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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623638
Report Date: 01/08/2021
Date Signed: 01/08/2021 04:24:32 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:RUTHERFORD, JENNIFERFACILITY NUMBER:
313623638
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
01/08/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Jennifer RutherfordTIME COMPLETED:
04:30 PM
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NOTE: Due to Covid-19 and DPH guidelines on physical distancing, a Tele-visit via FaceTime was conducted. On Friday, January 8th, 2021, at 4:05pm, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management visit for the purpose of increasing the maximum capacity from 8 to 14 children. At the beginning of the tele-inspection, the Licensee was asked how many children were present, replying that there were no children at that time. The Fire Safety Inspection Clearance has been received and the home has been cleared for up to 14 children. At 4:07pm, with the help of the Licensee, a health and safety inspection of all areas accessible to children was conducted. The Off-limits areas has not changed and includes the Entire 2nd Floor, Outbuildings, and Garage. Licensee acknowledged that children may never enter these off-limit areas. Current CPR/First Aid certificate (expires: 3/2021), posted License, Parent's Rights, Emergency Disaster Plan, Roster of the enrolled children, and Fire Drill Log are all being maintained by the Licensee. Hazardous items were stored inaccessible to children in care. Licensee stated there are no weapons in the home. Fire extinguisher (2A10BC), carbon monoxide and smoke detector meet regulation. The outdoor area used by children at this time is partially fenced and age appropriate toys were observed. The Licensee understands that 100% supervision is required in any unfenced areas. There are no bodies of water on the premises. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes. In the areas that were evaluated, no deficiencies were observed at the time of the visit. Please note: When a physical inspections takes place, requests for alterations may be made.
Capacity increase is approved as of today, 1-8-2021. The facility is licensed to serve a MAX. CAP(WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.
This report (LIC 809), Appeal Rights (LIC 9058) and a Notice of Site Visit (LIC 9213) will be delivered to the Licensee electronically via email.
Acknowledgement of delivery will constitute acknowledgement of the report in lieu of a signature
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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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