455402479-1-2-2020-13-CC-JSNW-BKFUBX-20200102142705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455402479
Report Date: 01/02/2020
Date Signed: 01/02/2020 02:27:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	MATTICE, STEPHANIE FAMILY CHILD CARE HOME		FACILITY NUMBER:	455402479
ADMINISTRATOR:	MATTICE, STEPHANIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 440-9399
CITY:	SHASTA LAKE	STATE: CA	ZIP CODE:	96019
CAPACITY:	14	CENSUS: 7	DATE:	01/02/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Stephanie Mattice		TIME COMPLETED:	02:45 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	An Annual inspection was made to the facility by Licensing Program Analyst (LPA), Snow A review of staff records on 12/20/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 3 adults living in the home. During today’s inspection the home and grounds were toured. The licensee and assistant were supervising 7 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30 AM to 5:30 PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. Only the bedrooms are off-limits by way of doorknob covers. The home was clean and orderly, and was at a comfortable indoor temperature of 78 degrees. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The licensee's pediatric CPR and First Aid is current. The Last fire drill is within the required 6 months; was done in August of 2019.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2020

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MATTICE, STEPHANIE FAMILY CHILD CARE HOME	FACILITY NUMBER: 455402479
	VISIT DATE: 01/02/2020

NARRATIVE

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There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The wall heater is screened. The licensee's weapons and ammunition were stored appropriately. The children use the backyard as the outdoor play area and it is fully fenced. There is a pool in the backyard. There is a waiver in place that allows for a six foot chain-link fence with slats and the conditions of the waiver were being met. There was evidence in file of required immunization records for the licensee and her assistant. Five children's records were reviewed at 1:40PM; required emergency information was observed to be on file. The licensee is not currently providing Incidental Medical Services – IMS.. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

No violations issued during the visit.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2020

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MATTICE, STEPHANIE FAMILY CHILD CARE HOME	FACILITY NUMBER: 455402479
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES	PLAN OF CORRECTIONS(POCs)
	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3