414002814-9-27-2022-05-CC-CQUO-CJNPQ4-20220927113029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002814
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:31:28 AM

Document Has Been Signed on 09/27/2022 11:31 AM - It Cannot Be Edited

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 & KATHLEEN		FACILITY NUMBER:	414002814
ADMINISTRATOR:	STACIE & KATHLEEN CROCKETT		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 350-1059
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 10	DATE:	09/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Stacie & Kathleen Crockett		TIME COMPLETED:	11:35 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 27, 2022 at approximately 9:15am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensees, Stacie and Kathleen Crockett, and explained the purpose of the inspection. Present during LPA's visit included 10 enrolled children (3 infants and 7 preschool age). Licensee is operating within capacity limits and ratio during LPA's visit. All adults living and/or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 7:00am to 6:00pm. Licensee live in the home which is a single level home with 3 minor children. The DAY CARE AREAS are the living room, nap room, bathroom and backyard. The OFF-LIMIT AREAS are 2 bedrooms, kitchen, garage and storage shed in backyard area. Off limit areas are made inaccessible to children with child safety gates. LPA inspected day care areas for health and safety hazards. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of age appropriate toys and materials that were in good working condition. LPA observed cleaning supplies, poisons and other chemicals to be made inaccessible to children behind child safety locked cabinets and located in off limit areas. Home has a fire place that is properly barricaded and made inaccessible to children in care. Home is equipped with multiple carbon monoxide detectors, smoke detectors and fire alarm system. Home is also equipped with multiple fully charged fire extinguishers, fully stocked first aid kits and working phone on site. Phone number listed for licensees is current. Per licensee, there are no weapons or firearms in the home. LPA observed required licensing documents to be properly posted, available for review. (Continue Report on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 & KATHLEEN	FACILITY NUMBER: 414002814
	VISIT DATE: 09/27/2022

NARRATIVE

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Entire backyard is fenced with an at least 5 ft. high fence. LPA did not observe any pools, spas or bodies of water on the property. Backyard is equipped with appropriate outdoor toys and equipment that are in good working condition. Backyard includes a storage shed that is made off limits to enrolled children.

LPA reviewed 10 children's records which were complete. Children's files have a record of emergency identification information on file. LPA reviewed both licensees' files which were also complete. Both licensees have a current CPR certificate that will expire 08/2023. Licensees also have required immunizations that were made available for review. Last emergency drill conducted was 09/01/2022. Emergency drills are conducted monthly and are properly logged.

During Inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation.
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training at www.mandatedreporterca.com. Training must be completed every two years by licensee and all staff hired.

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: www.ada.gov/childqanda.htm.

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

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 & KATHLEEN	FACILITY NUMBER: 414002814
	VISIT DATE: 09/27/2022

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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 in a 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.

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.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Stacie Crockett.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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