344500040-7-5-2019-53-CC-ASIA-BDSN84-20190705101344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 344500040
Report Date: 07/05/2019
Date Signed: 07/05/2019 10:13:52 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:	HARRIS-POTCH, JILLIAN		FACILITY NUMBER:	344500040
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	07/05/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jillian Harris-Potch		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 Analyst (LPA) Amy Silva met with the Licensee Jillian Harris-Potch for the purpose of a pre-licensing inspection for a change of location. Licensee was previously licensed under facility #343622253. Licensee and spouse living in the home have a criminal record clearance. Licensee rents the home and plans to provide care for up to eight children at this time. The Licensee understands that consent must be obtained from the landlord prior to providing care to more than 6 children and up to 8 children. A health and safety inspection was conducted inside and out. The one story home has an unfenced front yard, 3 bedrooms, 3 bathrooms, a living room, kitchen, laundry room, fenced backyard and a fenced side yard. The off-limits areas in the home will be the master bedroom and master bathroom, kitchen, living room, laundry room, bathroom located in the back left of the home, garage, shed and the left side of the backyard. The fire place in the living room is appropriately screened to prevent access to children and is located in an off-limit area. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detector and a 3A10BC fire extinguisher were observed in the home. Current pediatric CPR and first aid training was verified. Licensee stated there are no weapons in the home. There is no pool at the home. No other bodies of water were observed at the home. *Report continued on 809-C*

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy Silva	TELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2019

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: HARRIS-POTCH, JILLIAN	FACILITY NUMBER: 344500040
	VISIT DATE: 07/05/2019

NARRATIVE

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Licensee has completed the required AB1207 Mandated Reporter training. Licensees understand that the training must be completed once every two years, and that Mandated Reporter training offered outside of http://childcare.mandatedreporterca.com/ , must be approved by the department.

Licensee understand 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. Licensee understand that if anyone else works with the children, must also obtain the following: EMSA certified CPR and first aid training, immunization for Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.

Licensee understand that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Licensee understand that the FCCH license is not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. LPA explained to the Licensees that if they move and want to continue to provide care, they must submit a change of location application and have the new home inspected again.

Licensee understand 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 seven days to remain in compliance.

Licensee understand that if any structural changes are made to the home; licensing must be notified prior to construction. Licensee understand that if they want to make any off-limit areas an ON-limits for children, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.

Licensee understand that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years. Licensee understands that their License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home. Licensee will have the forms posted in the home.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy Silva	TELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2019

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: HARRIS-POTCH, JILLIAN	FACILITY NUMBER: 344500040
	VISIT DATE: 07/05/2019

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

This facility evaluation report was reviewed and discussed with the Licensee. Records, postings and reporting requirements were discussed. Licensee was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

LPA reviewed with licensee the handouts “A Child Care Provider’s Guide to Safe Sleep” and “Safe Sleep Regulation Concepts” and "Lead Poisoning Facts" and gave her a copy of these handouts.

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report with the Licensee and provided copies. An exit interview was conducted. Appeal rights provided. Notice of Site Visit given and Licensee understands it must remain posted for 30 days.

As of today 07/05/2019 facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy Silva	TELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2019

LIC809 (FAS) - (06/04)

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