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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622051
Report Date: 08/30/2019
Date Signed: 08/30/2019 01:58:08 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:GAINES, ANGELAFACILITY NUMBER:
343622051
ADMINISTRATOR:GAINES, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 910-5643
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 3DATE:
08/30/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Angela GainesTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Marea Behvand met with Licensee Angela Gaines for the purpose of an unannounced annual random inspection. Licensee's sister was also present during the inspection.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the four bedrooms, the master bathroom, and the garage. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. The fireplace is appropriately barricaded to prevent access by children and outdoor play space is fenced.

LPA reviewed children records and provided a 311D as a reference. A current roster is being maintained and fire and disaster drills are documented. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires 07/22/2021.

This provider is currently not providing IMS services to children in care. 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.
Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019
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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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: GAINES, ANGELA
FACILITY NUMBER: 343622051
VISIT DATE: 08/30/2019
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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 and discussed the Safe Sleep in Child Care brochure, Effects of Lead Exposure brochure, and the new blue immunization card.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2