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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500345
Report Date: 12/03/2020
Date Signed: 12/03/2020 03:06:22 PM

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:SMITH, STARVEINAFACILITY NUMBER:
394500345
ADMINISTRATOR:SMITH, STARVEINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 635-2818
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:14CENSUS: 2DATE:
12/03/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Starveina SmithTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Fabiola Diaz conducted a tele-inspection due to COVID-19 State of Emergency for the purpose of a change of location. The tele-inspection was conducted on FaceTime. Applicant Starveina Smith applied for a change of location for a large family child care home. Applicant's previous license number is #393622369. Applicant’s adult daughter and grandchild were present during the tele-inspection. Applicant was caring for two children from one family only.

The family child care home facility is a one story family home with a front yard with 3 bedrooms, 2 bathrooms, a garage, kitchen, dining room, living room, a kids room, laundry room, and a fenced backyard with an out house. Off-limit areas are: laundry room, all bedrooms, out house, and garage. All off limit areas must be made inaccessible to children. All individuals subject to criminal background review have obtained a criminal record clearance. The day care hours of operation are Monday through Friday, 6 AM to 6 PM. The facility received a fire clearance on 11/23/20 by the Stockton Fire Prevention Department.

LPA tele-inspected the inside and outside of the home with the applicant for health and safety hazards. All the toxic or hazardous materials are inaccessible to children. LPA advised the applicant that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. The house has a working telephone, fully charged fire extinguisher, and a dual smoke and carbon monoxide detector that meet Title 22 regulations. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. There are no stairs. There is a properly barricaded fireplace in the facility.
Page 1. Report continues on LIC 809-C...
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
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: SMITH, STARVEINA
FACILITY NUMBER: 394500345
VISIT DATE: 12/03/2020
NARRATIVE
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LPA discussed licensing regulations and capacity requirements. Licensing forms and posting requirements were reviewed with the licensee. Prior to the tele-inspection, LPA observed licensee’s proof of home rental. Applicant's Mandated Reporter Certification expires 11/30/2022 and Applicant's Preventative Health and Safety Training was completed on 07/01/2017. LPA observed the record of applicant’s immunizations on file. Applicant is enrolled to take the Lead Poisoning Prevention component course for the Preventative Health and Safety training on 12/10/2020. Applicant has the required postings in a conspicuous place. LPA informed the applicant that Fire Drills need to completed every six months.

Applicant was encouraged to maintain supervision at all times. LPA discussed requirements for staff, adult assistants, and adults living in the home. LPA discussed the new Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against, Pertussis, Measles and Influenza (influenza is optional). Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Applicant understands that a current roster must be maintained. 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. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected. 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.

LPA discussed the inspection authority of the Department by authorized agent to enter and inspect the family child care home providing care, supervision and services at any time, with or without advance notice to secure compliance with the regulations in accordance with Section 102396. LPA discussed that prior to making alterations or additions to a family child care home or grounds, the applicant shall notify the Department of the proposed changes. The applicant is encouraged to frequently visit website at http://www.ccld.ca.gov for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates. LPA has e-mailed applicant the new Safe Sleep Regulations, and they were discussed with applicant today.


Page 2. Report continues on LIC 809-C...
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
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: SMITH, STARVEINA
FACILITY NUMBER: 394500345
VISIT DATE: 12/03/2020
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LPA also discussed Unusual Incident Reports (UIRs) and reporting requirements. LPA informed the applicant that if any unusual incidents occur she must contact the Department within 24 hours and a UIR must be submitted with 7 days, describing the specifics to the incident.
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

As of today, 12/03/2020 the facility is still pending clearance of TB test results for an adult in the home. Once the TB test results are submitted, the facility can be granted a provisional license for 90 days for 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.

Applicant will need to submit verification of the Lead Poisoning Prevention training for applicant and current EMSA approved pediatric CPR/First Aid training for applicant before the provisional license expires. Once these two items (Lead Poisoning Prevention training for applicant and current EMSA approved pediatric CPR/First Aid training for applicant) are submitted to the Department, the provisional status will be removed and a regular license will be issued. The provisional license will expire after 90 days from when it is issued.

An exit interview was conducted. A copy of this report was e-mailed to the applicant to keep on file at the facility. A “read receipt” and/or an e-mail from applicant stating applicant has read this report is in lieu of a signature due to COVID-19. Applicant stated she is also able to sign the report and provide a copy to LPA.

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SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3