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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384003092
Report Date: 07/29/2019
Date Signed: 07/29/2019 11:18:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHAPMAN, NICOLEFACILITY NUMBER:
384003092
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
07/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nicole ChapmanTIME COMPLETED:
11:45 AM
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#1 Licensing Porgram Analyst (LPA), Mok conducted an unannounced annual inspection today. LPA met with the licensee, Nicole Chapman and licensee's mom who has fingerprint clearance. The purpose of the inspection was explained to them. There were 3 children that included 1 infants and 2 preschoolers present. Licensee owns this 2 stories single family house. Licensee lives in the house by herself. 2 bedroom, 1 sun room, 1 bathroom, kitchen, living room on the upper level; 1 office, garage and backyard on the lower level. The day care areas will be: living room, kitchen, bathroom, Bedroom #1, and the backyard. The outdoor play area is temporarily closed because the weeds have to be cleaned up before it's opened again. The off-limit areas will be: Bedroom #2, sun room, and the entire lower lever except backyard. LPA toured and inspected the facility for health and safety hazard. There were the fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors, working telephone, and first aid supplies available in the house. There were plenty of toys, books, play house, and learning material available for the children. Facility provides breakfast, lunch and PM snack to the children. Per licensee, there were no guns, no weapos, and no pets in the house. The children's bathroom was clean and free of harmful objects. The outdoor area was completely fenced. Carpet was installed to the floor in living room and bedroom #1 as the soft cushioning prevent injury. All lower kitchen cabinets and drawers were free of harmful obejcts. Child proof knobs were installed to the stove, Window locks were installed to the windows in the living room and kitchen. Gates were used at the stairway and the kitchen entrances to prevent children access to the off-limit areas. Play pens and mats were used for napping. High chairs were available for feeding only. All electrical outlets were covered. Licensee had current CPR/First Aid training, it will expire in 5/2020. Per licensee, there was no children on special medication 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 facilities and the ADA, available at: http://www.ada.gov/childqanda.htm. All required postings were posted. Children files and roster were reviewed during the inspection.

This report and notice of site visit were discussed with the licensee and must be made available to the public upon request. For quarterly update on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
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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