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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406213123
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:10:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:MCKENZIE FAMILY CHILD CAREFACILITY NUMBER:
406213123
ADMINISTRATOR:JAMIE MCKENZIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 423-3188
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:14CENSUS: 5DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Jaime McKenzieTIME COMPLETED:
11:15 AM
NARRATIVE
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On 9/2/2021 at 9:08am, Licensing Program Analyst (LPA) Melissa Stewart conducted a Facility Risk Assessment for COVID19 with Licensee, Jaime McKenzie. All answers indicated no exposure to COVID19. The purpose of the visit, Required 1 year inspection, was explained. At the time of inspection, Licensee was supervising five children, two (2) of which were infants, in the backyard. The outdoor activity area for children is fully fenced. There are a variety of activity areas such as grass, sandbox, play house and play boat, along with a swing set with wood chips for cushioning a fall. Licensee has one small dog and two (2) chicken coops in the children's activity area. The backyard extends beyond the children's activity area and includes an above ground pool that is made inaccessible by a metal fence and gate with self locking mechanism which meets the regulation.

Indoors, LPA observed age appropriate toys in the living room. There is fireplace in the living room with glass doors. Licensee stated that the fireplace is not used when children are present. LPA observed required documents are in an area easily viewed by parents. There are two (2) cribs in the first bedroom for napping infants. LPA advised that the door to the room must be kept open while infants are sleeping. Licensee indicated that she understands this requirement. The bathroom used by children was observed to be clean and free of toxins.

Licensee stated there are no guns or ammunition in the home. Detergents, cleaning compounds, medications and other items such as kitchen knives which could pose a danger to children are inaccessible to children. Smoke and Carbon monoxide detectors were tested and found to be operational. LPA observed the 2 A10 BC fire extinguisher with a service date of 10/28/2020. Licensee was reminded to service or replace the fire extinguisher yearly. Licensee completes and documents emergency drills. The most recent drill was held on 7/20/21.

Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MCKENZIE FAMILY CHILD CARE
FACILITY NUMBER: 406213123
VISIT DATE: 09/02/2021
NARRATIVE
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Licensee has current Pediatric CPR and first aid expiring on 10/9/2021. Licensee has not met SB 792 immunization requirement. Licensee must renew Mandated Reporter Training per AB 1207 as it was originally completed in 2018 and must be renewed every two years. Licensee stated that she will renew the AB1207 training and email or text a photo of completion certificate to LPA on or before 9/30/21. Facility roster has not been updated. Licensee stated that she will submit a photo of updated facility roster on or before 9/10/2021. A sample of children's records were reviewed. Three (3) files were found to be missing current immunization records.

Infant Safe Sleep Regulation section 102425 was discussed. LPA provided PIN 20-24-CCP, Individual Infant Sleep Plan (LIC9227) and a sample Infant Sleep Log for 15 minute checks of all children under the age of two (2) years. LPA provided the “Effects of Lead Exposure” brochure to be distributed to all families at time of enrollment. Licensee stated that she is subscribed to receive Provider Information Notices (PINs) from Community Care Licensing Division via email. LPA advised Licensee that Title 22, Division 12 regulations for Family Child Care Homes and California Department of Public Health COVID-19 guidelines for child care programs can be accessed on-line at www.cdss.ca.gov. COVID19 Information for San Luis Obispo County can be found at www.emergencyslo.org.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that there are no children enrolled who require medications at this time. 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: www.ada.gov/childqanda.htm

Deficiencies cited today in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Jaime McKenzie, whose signature on this form confirm receipt of these documents.

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: MCKENZIE FAMILY CHILD CARE
FACILITY NUMBER: 406213123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited

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Employees or volunteers at family day care home; immunization requirements; records; exemptions (c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization.... This requirement if not met as evidenced by:
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Licensee stated that she has been immunized against pertussis and measles, but did not have a record of immunization or other proof of immunity. Licensee stated that she declines the infuenza vaccinne. Licensee did not ensure that she has a record of her immunity on file which poses a potential risk to the health and safety of children in care.
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Type B
09/30/2021
Section Cited

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102418 Immunizations(a) Prior to admission to a family day care home, children shall be immunized against diseases as required ... (1) This requirement includes updating each child's PM 286 (6/95) ... after enrollment in the family day care home.
This requirement is not met as evidenced by:
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Based on record review: C1 and C3 did not have any record of immunizations (both enrolled more than 30 days). C2 has a PM286 on file which has not been updated since enrollment in 2018. Licensee did not ensure that children have been immunized as required and has not updated the PM286 as required which poses a potential risk to the health and/
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or safety of children in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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