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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618616
Report Date: 07/10/2019
Date Signed: 07/10/2019 03:19:56 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:SMITH, JENNIFER ANNFACILITY NUMBER:
343618616
ADMINISTRATOR:SMITH, JENNIFER ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 332-2563
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:14CENSUS: 12DATE:
07/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jennifer A. SmithTIME COMPLETED:
03:45 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Kelly met with licensee for the purpose of an annual/random inspection. LPA toured the home inside and backyard. There were 12 day care children in care at time of inspection.

Off-limit areas: Entire second floor, sheds and detached garage.
Today, the home was inspected inside and out and the following was observed by LPA:
-Knives, medications, first aid kit, and cleaning compounds were inaccessible to the children.
-LPA observed a working Smoke, and a Carbon Monoxide detectors, and a fully charged 2A10BC fire extinguisher
-Current CPR/First Aid certificate.
-Backyard is fenced, free from apparent safety hazards, and there were no bodies of water
-The toys appear to be safe and in good condition
-All sharp knives are stored out of reach
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-Licensee stated there are no weapons/firearms in the home
-All adults in the home are fingerprint cleared
-Cleaning compounds are stored out of reach of children
-The bathroom was free of any hazardous items
-Medication are out of reach of children
-Posted license, parents rights, and emergency disaster plan
-LPA reviewed children's record, roster and fire drills documentation
--LPA discussed and reviewed Health & Safety code: 1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions with licensee. 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. 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 and the ADA, available at: http://www.ada.gov/childqanda.htm
-There is a working telephone in the home
-LPA did not observed children alone in parked cars
-Provided licensee with website www.ccld.ca.gov to obtain forms and Title 22 Regulations.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Socorro KellyTELEPHONE: (916)216-7792
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
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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