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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412306
Report Date: 05/29/2019
Date Signed: 05/29/2019 11:16:26 AM

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:CLELAND, MICHELLEFACILITY NUMBER:
444412306
ADMINISTRATOR:CLELAND, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 763-2891
CITY:LA SELVA BEACHSTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 13DATE:
05/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle ClelandTIME COMPLETED:
11:25 AM
NARRATIVE
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Unannounced random visit made by Mahvash Behbood. Met licensee Michelle Clealand, purpose of the visit explained. Present also were 13 day care children, all between 2 and 5 and her assistant. Days and hours of Day care operated Mondays and Wednesdays from 8: to 12:30 and on Tuesdays and Thursdays from 8 to 4. No day care on Fridays. Day care is provided in the detached building. Inside and outside of the day care inspected. Children and staff file reviewed. She agreed to update LIC 610 ( Emergency Disaster Plan and her facility sketch. Effects of Lead Exposure Poster was provided and she agree to share the poster with all her parents. There are no bodies of water on the property.
Licensee stated there are no gun at home.
Cleaning supplies stored inaccessible to children.
No fire place in day care area. Fire extinguisher is the correct size. Smoke and carbon monoxide are operational. She uses electric heaters and fan to heat and cool the room.
Toys and play equipment are safe and age appropriate.
Telephone is working and the phone number is still the same.
Children were supervised during the visit.
Backyard where children play is fenced, and there are plenty of appropriate play equipment.
Licensee's roster was up to date. There is emergency information on file for all children in care.
The fire/disaster drill log is not updated.
The adults who live in the home are licensee and her helper Darienne, both have criminal record clearance on file
CPR and First Aid is expired on 02/2020 .
No medication or IMS is provided.

Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
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 2
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: CLELAND, MICHELLE
FACILITY NUMBER: 444412306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2019
Section Cited
HSC
1597.622
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IMMUNIZATION SB792-a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles-Licensee and her subs don't have proof of immunization against above diseases. This is potentially dangerous to health and safety of the children.

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Proof of immunization for staff/sub including licensee must be sent to analyst no later than 06/12/19.
Type B
06/12/2019
Section Cited
CCR
102369(b)(9)
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TB- Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care. None of staff have proof of TB clearance in their file. This is potentially dangerous to health and safety of the children.

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Proof TB clearance for staff/sub including licensee must be sent to analyst no later than 06/12/19.
Type B
06/12/2019
Section Cited
HSC
1596.8662(b)
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Training on Mandated Reporter for Child Abuse. None of staff have completed the training.
This is potentially dangerous to health and safety of the children.
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Certificate of training completion must be received no later than 06/12/19.
Type B
06/12/2019
Section Cited
CCR
102418(a)
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Immunizations-Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. Children #1,2,and 3 don't have proof of immunizaitons in their files. This is potentially dangerous to health and safety of the children.
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Proof of immunizations for these children must be forwarded to analyst no later than 06/12/19.
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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2