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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500040
Report Date: 06/14/2021
Date Signed: 06/14/2021 11:22:44 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, JILLIANFACILITY NUMBER:
344500040
ADMINISTRATOR:HARRIS-POTCH, JILLIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 833-4089
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 4DATE:
06/14/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jillian Harris-PotchTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Amy Silva met with Licensee, Jillian Harris-Potch for an unannounced random annual inspection. Also present at today's inspection was Assistant, Molly Harris-Potch. LPA observed four children in care. LPA toured all areas of the home that are accessible to children. 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. Licensee acknowledges that children may never enter these off-limit areas. The fire place in the living room is appropriately screened to prevent access to children and is located in an off-limit area.

At 10:45 AM LPA observed a functioning smoke and carbon monoxide detector and a 3A10BC fire extinguisher was observed in the home. LPA observed current CPR/First Aid certificate for Licensee, which expires 5/23/23 and a current Mandated Reporter training certificate which expires in June of 2023. Toxic and hazardous items are inaccessible to children. LPA did not observe any bodies of water at the home. Licensee states there are no weapons or firearms in the home.

The capacity as specified on the license is being maintained. Staff-child ratios are maintained. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. A child roster is maintained. Fire and disaster drills are conducted every six months and documented. Four of six child records were reviewed.

Continued on LIC809C

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: 06/14/2021
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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.

LPA reviewed with licensee the handouts “A Child Care Provider’s Guide to Safe Sleep” and “Safe Sleep Regulations,” and "Lead Poisoning Facts."

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 was provided and Licensee understands it must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2