376620900-8-19-2021-20-CC-CGUY-C62RD8-20210819125531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376620900
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:55:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	BACKUS, AUTUMN FAMILY CHILD CARE		FACILITY NUMBER:	376620900
ADMINISTRATOR:	AUTUMN BACKUS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 869-4177
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	14	CENSUS: 3	DATE:	08/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Autumn Obry		TIME COMPLETED:	01:10 PM

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	On 8/19/21, Licensing Program Analysts (LPAs), Casey Gulley and Cindy Meier conducted an unannounced Annual Required Inspection and met with the Licensee, Autumn Obry. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Three (3) children and two (2) staff were present in the facility during this inspection. This facility is a one story, four-bedroom, two-bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: bedroom four, living room, kitchen and bathroom one . off limits areas are Master bedroom, bedroom two and bedroom three and are inaccessible through use of door knob covers. The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. The home has a fenced backyard available for outdoor activities. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications expire on 3/22/21. Licensee has required immunizations. Licensee completed Mandated Reporter Training on 3/22/21 . Facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 5/14/21. There is one crib or play yard for each infant who is unable to climb out of the crib or play yard.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Casey Gulley	TELEPHONE: (619) 767-2216
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: BACKUS, AUTUMN FAMILY CHILD CARE	FACILITY NUMBER: 376620900
	VISIT DATE: 08/19/2021

NARRATIVE

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Cribs or play yards are free from all loose articles and objects. An Individual Infant Sleeping Plan is maintained for each infant up to 12 months of age. The provider places infants up to 12 months of age on their backs for sleeping.

LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding upcoming Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

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.

No deficiencies cited.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Casey Gulley	TELEPHONE: (619) 767-2216
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

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