426205523-3-2-2023-17-CC-GRES-CPJSZC-20230302131856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:19:05 PM

Document Has Been Signed on 03/02/2023 01:19 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	BORNEMAN FAMILY CHILD CARE		FACILITY NUMBER:	426205523
ADMINISTRATOR:	TRACEY ANN BORNEMAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 264-8444
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	14	CENSUS: 6	DATE:	03/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Tracey Borneman		TIME COMPLETED:	01:25 PM

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 March 2, 2023 at 11:10 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced One (1) Year Required inspection. LPA asked pre- screening questions related to COVID- 19 and licensee’s responses indicate there are no COVID 19 exposures on site. LPA met with licensee, Tracey Borneman and explained the purpose of the inspection. There were 6 day care children at the time of the inspection. LPA in the company of Licensee toured the interior and exterior of the day care. Required licensing forms are posted in the wall by the entrance. LPA observed age appropriate toys, activities and equipment. LPA observed smoke and carbon monoxide detectors in the FCCH The fire extinguisher was serviced on 5/19/2022. FCCH conducts and documents fire and disaster drill every month last drill, was conducted on 2/2/2023. Bathroom was observed to be clean and free of toxins. Hazardous items and cleaning materials are kept inaccessible to day care children. The backyard is enclosed with appropriate fence equipped with age appropriate play equipment. No bodies of water were observed on site. Licensee stated there are no guns or ammunition in the home. LPA observed Licensee uses sleep sacks for infant. LPA advised licensee that the use of sleep sacks as a swaddling alternative would require a waiver and can be considered on a case by case basis. Waivers need to address the length of time they will be used and how they will be used safely LPA reviewed facility file, Pediatric CPR and First Aid expires on 5/19/2023. Licensee renewed Mandated Reported Training which will expire on 3/15/2024. Licensee has required immunization record on file, Continued on LIC 809C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: BORNEMAN FAMILY CHILD CARE	FACILITY NUMBER: 426205523
	VISIT DATE: 03/02/2023

NARRATIVE

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FCCH has current roster of children in care. A sampling of children records were reviewed and found to be complete. Licensee physically checks and documents napping infants every 15 minutes. LPA observed that LIC 9227 Infant Safe Sleep Plan are filled out and signed.

Licensee does not provide Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home 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.

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep Regulation, the frequently asked questions (FAQ) and the Safe Sleep Regulation web page 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

Licensee was reminded that all adults 18 year old 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.

Continued on LIC 809 C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: BORNEMAN FAMILY CHILD CARE	FACILITY NUMBER: 426205523
	VISIT DATE: 03/02/2023

NARRATIVE

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During today's inspection, no deficiency was cited. Technical Advisory and Technical Violation were issued. Appeal Rights were given and discussed.

Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted and report was reviewed with the licensee, Tracey Borneman

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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