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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002814
Report Date: 10/15/2019
Date Signed: 10/15/2019 03:37:26 PM

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:CROCKETT, STACIE & KATHLEENFACILITY NUMBER:
414002814
ADMINISTRATOR:STACIE & KATHLEEN CROCKETTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 350-1059
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:14CENSUS: 13DATE:
10/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Stacie CrockettTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Faye Bremer conducted an unannounced Annual inspection. LPA met with Licensee Stacie Crockett and explained purpose of inspection. There were 13 children present with 3 staff upon LPA's arrival.

LPA toured and inspected the physical plant for any health and safety hazards. Day Care Areas: Main Room, Art Room, Nap Room, Bathroom and Backyard. Off limit areas: Two Bedrooms, Kitchen and Garage. Off limit areas are gated off to prevent access. There is no pool, spa or any other body of water in the house. Per licensee, there are no firearms or weapons in the house. All the cleaning supplies, poisons and other chemicals are stored in garage and inaccessible to the children. The fireplace completely barricaded. The house is in good repair and free of hazards. Home was at a comfortable temperature, with sufficient ventilation. Carbon monoxide detector, smoke detector, and a fully charged fire extinguisher was observed present in the house. A variety of age appropriate toys were observed in the house.

LPA reviewed children's records. All children's files reviewed have all required assessments, agreements, and documents.

LPA reviewed staff records. All staff are fingerprint cleared and associated to the home. All staff have all required training, and health assessments. Licensee has required training of preventive health and current CPR card, valid until April 2020.

Licensee has all required posters posted on the wall in front of the kitchen, next to nap room. Emergency drills are conducted and logged, with last emergency drill conducted on September 12, 2019.

No deficiencies are cited toady.
Report reviewed, discussed and provided to Licensee Stacie Crockett
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Faye BremerTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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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