344500102-10-23-2019-53-CC-FDIZ-BH8N63-20191023101027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 344500102
Report Date: 10/23/2019
Date Signed: 10/23/2019 10:10:40 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:	JOHNSON, COURTNEY ANNE		FACILITY NUMBER:	344500102
ADMINISTRATOR:	JOHNSON, COURTNEY ANNE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 402-7248
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	14	CENSUS: 0	DATE:	10/23/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Courtney Anne Johnson		TIME COMPLETED:	10:30 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) Fabiola Diaz and Joleen Kenney met with Applicant Courtney Anne Johnson for a Change of Location inspection. LPAs toured all areas of the two story home. The home consists of 6 bedrooms, three bathrooms, laundry room, garage, living room, kitchen area, two daycare rooms, and fenced in back yard. Off limits areas include: entire upstairs, garage, and closet under stairs. Applicant provided a copy of her MMR immunization record. Applicant is currently enrolled to take the Preventative Health and Safety Training on 11/02/19. LPA verified a current CPR/First Aid certification. All adults in the home have criminal record clearances. LPA observed no bodies of water on the property. Licensee provides proper storage for weapon in the home. Toxins and dangerous items were found inaccessible. The smoke alarm and fire extinguisher meet Title 22 regulations. LPA discussed the requirements for an operating carbon monoxide detector. Licensee will submit proof of installed carbon monoxide detector prior to an approved license. Applicant acknowledges that 100% supervision must be maintained in unfenced areas of the front yard. Applicant is applying for a large family care home license. LPA verified that applicant was operating as a large family child care home in the previous address. LPA received the fire clearance for the home from the Elk Grove Fire Department and it is on file with the department. Applicant has completed the required AB1207 Mandated Reporter training. Applicant understand that the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com. [Report continues on LIC809-C]

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 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: JOHNSON, COURTNEY ANNE	FACILITY NUMBER: 344500102
	VISIT DATE: 10/23/2019

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
26
27
28
29
30
31
32

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 provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.
LPAs provided and discussed the Safe Sleep in Child Care brochure and the Effects of Lead Brochure.
Applicant 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.

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. 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.

[Report continues on LIC809-C]

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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: JOHNSON, COURTNEY ANNE	FACILITY NUMBER: 344500102
	VISIT DATE: 10/23/2019

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
26
27
28
29
30
31
32

This facility evaluation report was reviewed and discussed with the applicant. LIC 311D, records, postings, and reporting requirements were discussed.

Effective November 4, 2019, LPA is granting 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 in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola Diaz	TELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3