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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621390
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:34:23 PM


Document Has Been Signed on 07/26/2023 12:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:STEPHEN, DAISYFACILITY NUMBER:
393621390
ADMINISTRATOR:STEPHEN, DAISYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 802-7171
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY:14CENSUS: 11DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Daisy StephensTIME COMPLETED:
12:20 PM
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On July 26, 2023, Licensing Program Analyst (LPA) Stacey Williams conducted an unannounced annual inspection and met with Licensee, Daisy Stephens . LPA observed eleven children supervised by Licensee and her Assistant . Criminal record clearances have been verified. Facility fees were reviewed and are current. Licensee stated there are no new residents in the home since licensure. Licensee operation hours are Monday- Friday: 8:30 AM- 5:00 PM and does not provide overnight care.

LPA and Licensee toured the facility during the inspection. Off limit areas: entire upstairs, master bedroom and the garage. The backyard is fenced. There are no bodies of water at the home. The outdoor area has a trampoline that is secured to the ground and has mesh netting that surrounds the unit. Licensee was advised that manufacture’s guidance for age requirements is to be met at all times while in use during childcare hours. Licensee stated that there is a pet dog in the home that does not interact with the children in care. Licensee stated there are no weapons in the home.

LPA conducted record reviews during the inspection. Child files, Licensee, and her Assistant’s files were reviewed. LPA discussed mandated reporter training with the Licensee. Licensee and her Assistant have current Mandated Reporter training on file. Licensee understands Mandated Reporter training is to be completed every two years. CPR/First Aid certification was reviewed for Licensee. Certification expiration date is 2/2024. LPA observed that Licensee has current fire drills logs with drills being conducted at least once every six months and documented.

LPA observed that there were no hazardous items accessible to children. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation standards. Toys appear to be safe.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence of the licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

REPORT CONTINUED ON SUBSEQUENT PAGE, LIC 809 C

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STEPHEN, DAISY
FACILITY NUMBER: 393621390
VISIT DATE: 07/26/2023
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This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA Information 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 discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

No Title 22 deficiencies observed in the areas evaluated during the inspection.

LPA reviewed report with the Licensee, Daisy Stephens and provided copies of the report along with Appeal Rights. A notice of site visit was provided and posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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