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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623028
Report Date: 05/16/2019
Date Signed: 05/16/2019 03:15:59 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:EDWARDS,SHANAFACILITY NUMBER:
343623028
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
05/16/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shana Edwards, ApplicantTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Mai Lor and Kelly Ferrara met with applicant Shana Edwards for the purpose of a pre-licensing inspection. LPAs toured the interior and exterior of the five bedroom, four bathroom home. The home was inspected for safety, comfort, cleanliness, and heating and ventilation. LPAs inspected for poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Areas accessible to children include: kitchen, family room, first bedroom on the right (play room), and bathroom.

Off-limit areas will consist of: Entire upstairs, laundry room, and both garages. Applicant understands that children may never enter these off-limit areas. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety.

Applicant and her husband live in the home. Applicant understands that children under 10 years old count as part of the ratio. Adults living in the home have received a criminal record clearance and are associated to the facility. Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Failure to obtain criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

LPAs observed a functioning smoke and carbon monoxide detector, and a 2A-10BC fire extinguisher to meet regulations. Hazardous cleaning products and chemicals, knives, and medications are properly stored and inaccessible to children. Poisons such as paint, weed killer and Raid are locked and stored inside the garage. Weapons and ammunition are stored accordingly to regulations. LPAs advised the applicant to let the analyst know if there are any changes that are made. The backyard is fenced and LPAs advised applicant that in areas that are not fenced, 100% supervision must be maintained at all times.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019
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: EDWARDS,SHANA
FACILITY NUMBER: 343623028
VISIT DATE: 05/16/2019
NARRATIVE
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The applicant owns the home and provided LPA with a copy of the deed to the home. Applicant is aware that she will need to have parents sign an affidavit stating that she does not have liability insurance at this time. Applicant stated she is looking into obtaining liability insurance for day care children. The applicant has completed the preventative health and safety training which includes the training on nutrition by an EMSA certified instructor as well as the Mandated Reporter training. Applicant understands that this training must be updated every two years online at www.mandatedreporterca.com, AB1207.

LPAs advised the applicant that any assistant that is hired must be over the age of 14 and is also required to have immunization records on file including Measles, Mumps, Rubella and Pertussis, take the Mandated Reporter training, and be fingerprint cleared and associated to the facility if over 18. The flu shot is also needed annually between August 1st and December 1st of each year or a declination letter to opt out of the shot. The applicant provided proof of immunization for herself and her husband.

LPAs discussed Type A and Type B citations, Zero Tolerance, and Civil Penalties with the applicant. LPAs discussed open door policy, supervision, fire drills, children’s personal rights, and the smoking prohibition with the applicant. LPAs discussed ratio and capacity limitations with applicant. Applicant stated that she plans to transport children at this time. LPAs advised applicant to comply with laws regarding using proper restraints during transportation. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. Annual fees must be paid promptly and by the due date or late fees will be assessed or the license will be terminated.

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.

LPAs provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPAs provided form LIC 311D and discussed the required forms for children's record, employee records, and forms required to be kept on file at the facility. LPAs provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, and forms.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: EDWARDS,SHANA
FACILITY NUMBER: 343623028
VISIT DATE: 05/16/2019
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Effective today May 16, 2019, LPAs recommend a license to serve up to either 8 children, two (2) of which must be school age children, one at least age 6 years of age, one enrolled in kindergarten and no more than two (2) may be infants; or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of two years old.

A copy of this report was given to the applicant to keep on file at the facility.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019
LIC809 (FAS) - (06/04)
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