343624175-3-11-2022-03-CC-FDIZ-CCEPRK-20220311103253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624175
Report Date: 03/11/2022
Date Signed: 03/11/2022 10:33:01 AM

Document Has Been Signed on 03/11/2022 10:33 AM - It Cannot Be Edited

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:	TATOM, TENISHA		FACILITY NUMBER:	343624175
ADMINISTRATOR:	TATOM, TENISHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 384-7263
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	14	CENSUS: 0	DATE:	03/11/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tenisha Tatom		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Fabiola Diaz and Erwin Tjhia conducted a case-management inspection with applicant, Tenisha Tatom, who requested a change of location. Applicant's adult daughter was present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety inspection was conducted inside and out the home. The two story home has 3 bedrooms, 2.5 bathrooms, office, a kitchen, day care room, laundry room, a living room, dining room, a garage, and fenced backyard with a shed. The off-limit areas in the home are entire upstairs, garage, shed, laundry room, and dog area in backyard. The home does have a barricaded fireplace and stairs. Licensee explained that the fireplace will not be used during day care hours. LPAs advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. LPAs observed the home to provide safe toys, play equipment and materials for the day care children. Toxic and hazardous items are inaccessible to children. LPAs observed a functioning smoke and carbon monoxide detector. LPAs observe a 2A-10B-C fire extinguisher in the home. A working telephone was observed. Applicant stated there are no weapons in the home. Current EMSA approved pediatric CPR and First Aid training was verified and expires 2/24. Applicant's CA AB1207 Mandated Reporter Training expires 1/25/24. Applicant completed the Preventative Health and Safety Training and the Lead Poisoning Prevention training. Page 1. Report Continues on LIC 809-C...

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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: TATOM, TENISHA	FACILITY NUMBER: 343624175
	VISIT DATE: 03/11/2022

NARRATIVE

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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

Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPAs provided and discussed the Safe Sleep in Child Care Regulations (and provided a copy). LPAs also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov.

Applicant was encouraged to maintain supervision at all times. LPAs discussed requirements for staff, adult assistants, and adults living in the home. LPAs discussed the new Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against, Pertussis, Measles and Influenza. LPAs observed proof of applicant's immunization in the facility file. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Page 2. Report Continues on LIC 809-C...

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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: TATOM, TENISHA	FACILITY NUMBER: 343624175
	VISIT DATE: 03/11/2022

NARRATIVE

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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPAs explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years.

On today's date the facility was granted a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.

An exit interview was conducted. Appeal Rights and Notice of Site Visit were provided. LPA observed the licensee post the Notice of Site Visit. The Notice of Site Visit must remain posted for 30 days.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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