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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618813
Report Date: 11/22/2019
Date Signed: 11/22/2019 10:14:14 AM

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:THOMAS-PICKETT, DELORESFACILITY NUMBER:
343618813
ADMINISTRATOR:THOMAS-PICKETT, DELORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 424-4150
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:14CENSUS: 8DATE:
11/22/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Delores Thomas-PickettTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mai Lor met with licensee Delores Thomas-Pickett for the purpose of an unannounced annual random inspection. LPA observed eight day care children, one under the age of two. Present during this inspection was Licensee's adult daughter acting as her assistant. Licensee stated there are no new adult residents in the home. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation are Monday through Friday 6:30am to 5:30pm.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include: all bedrooms, living room, side yard, and garage. LPA observed the required postings, a working phone, and functioning smoke and carbon monoxide detectors. Licensee stated there are no firearms/weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. The fireplace in the home is appropriately barricaded to prevent access by children and outdoor play space is fenced. LPA observed a 3A40BC fire extinguisher which the arrow was in recharge zone, which poses an immediate health and safety risk to persons in care. LPA did not observed a current children's roster and a current disaster and fire drill log, which poses a potential health and safety risk to persons in care.

Staff and a random sample of children’s files were reviewed. Children files contained emergency information and required immunization records. Staff's records contained mandated reporter training and immunization records. A current pediatric CPR and first aid certification was verified and expires 11/21.

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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: THOMAS-PICKETT, DELORES
FACILITY NUMBER: 343618813
VISIT DATE: 11/22/2019
NARRATIVE
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LPA verified that licensing fees are to update.

LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures.

LPA obtained a copy of the facility sketch (floor plan). LPA requested for a yard sketch plan.

Title 22 deficiencies are cited on the subsequent pages of this report.


Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.

Exit interview conducted. A notice of site visit was provided and posted.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: THOMAS-PICKETT, DELORES
FACILITY NUMBER: 343618813
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2019
Section Cited

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The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. This requirement was not as evidenced by:
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Based on observation, LPA observed a 3A40BC fire extinguisher that the arrow was in the recharge zone, which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: THOMAS-PICKETT, DELORES
FACILITY NUMBER: 343618813
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2019
Section Cited

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by: Based on records reviewed, LPA
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did not observe a current roster of children. Licensee stated she does not have one.
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Type B
12/13/2019
Section Cited

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Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement was not met as evidenced by: Based on record
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reviewed, LPA did not observe a current disaster and fire drill. The last disaster drill was conducted on 11/18/17.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4