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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621006
Report Date: 03/06/2020
Date Signed: 03/06/2020 03:28:58 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:STEPHENS, THEONIAFACILITY NUMBER:
343621006
ADMINISTRATOR:STEPHENS, THEONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 822-1048
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:14CENSUS: 4DATE:
03/06/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Theonia StephensTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Goodell met with licensee, Theonia Stephens, for the purpose of an Unannounced Annual Random Inspection. Hours of operation are Monday-Thursday, 7:00an -6:00pm and Friday, 7:00am- 5:00pm. During inspection LPA observed 4 children present with licensee. All individuals subject to criminal background review have obtained a criminal record clearance.

Inspection was conducted in all areas accessible to children. Off-limits areas include all three bedrooms, master bathroom, laundry room, and garage. LPA verified current phone number and email. LPA also observed a 3A40BC fire extinguisher, smoke and carbon monoxide detectors. No weapons or bodies of water. Licensee acknowledged the storage areas for poisons, firearms and other dangerous weapons shall be locked. Licensee acknowledged that 100% supervision is required in unfenced area. LPA observed cleaning compounds, medication and knives are stored inaccessible to children. Children's records were reviewed. LPA also observed fire drill log and children roster maintained. Preventative health training, current pediatric CPR and first aid certification was verified and expires 10/9/19. A copy of the Effects of Lead Exposure brochure was provided to licensee. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, forms, self-assessment guides, legislation and regulation information.

No Title 22 Deficiency cited. LPAs reviewed report with the licensee and provided copies. An exist interview was conducted. The Notice of Site Visit issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kristal GoodellTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
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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