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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414216
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:19:50 PM

Document Has Been Signed on 06/17/2021 03:19 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MARKUM, TIFFANY PENDLEYFACILITY NUMBER:
434414216
ADMINISTRATOR:MARKUM, TIFFANY PENDLEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 896-3550
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Tiffany Pendley MarkumTIME COMPLETED:
02:00 PM
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On 6/17/21 at 1:15pm: Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual/Required Inspection ( Tool Kit One) . LPA met with Licensee, Tiffany Pendley Markum. There was ventilation for safety and comfort. Licensee has a family pet (dog) who has current vaccinations.
Children were involved with age appropriate activity.under the supervision of the Licensee. Days and hours of operation are Monday - Friday from 6:00 AM -6:00 PM. Adults over the age of 18 and residing in the home are the Licensee and husband. All adults have Criminal Background Check Clearances, TB clearance and signed Criminal Record Statements LIC508 on file with Licensing Office. Licensee has a current CPR and First Aid card that expires on 11/12/2021. Last disaster drill was conducted on 12/9/2020.

The Licensee states that she lives in the home with her spouse and four (4) children, ages 15, 14, 12, and ten years old. LPA's observed four children ( preschool and school age, one of the school age child is the licensee's).

The fireplace, located in the living room, is barricaded. Detergents, cleaning compounds, medications, and other hazardous items are inaccessible to the children in stored in locked cabinets, located in the kitchen area of the home. LPA did not observe any baby bouncers or baby walkers inside the home. LPA observed sufficient age appropriate play equipment for the children in the home. The home is clean, orderly, and safe for the children. Off limit areas inside the home are all of the four bedrooms. There are no stairs inside the home. The off limits area outdoors: the right side portion of the backyard. Isolation room is inside the living room. Observed mats for the children take naps in the activity room.

The Licensee has a working telephone in the home. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters in the home.
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SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARKUM, TIFFANY PENDLEY
FACILITY NUMBER: 434414216
VISIT DATE: 06/17/2021
NARRATIVE
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LPA observed a fully charged 2A10BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home. Licensee states there are not firearms of weapons in the home. LPA did not observe any bodies of water on the property. Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children.

LPA's reviewed four of the Emergency Information Cards(LIC700) which were complete and updated. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who requires IMS. 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.

Licensee will be sending a copy of the Mandated Reporter Course Certificate to LPA by 6/18/2021. The last Mandated Reporter Certificate was reviewed. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed atwww.mandatedreporterca.com.

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates
(page 2)
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARKUM, TIFFANY PENDLEY
FACILITY NUMBER: 434414216
VISIT DATE: 06/17/2021
NARRATIVE
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Continued from 809c page 2.

No deficiencies are being cited based on the LPAs observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

LPA conducted an exit interview with the Licensee .

A NOTICE OF SITE VISIT WAS ISSUED, AND TO BE POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3