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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475403887
Report Date: 01/27/2022
Date Signed: 01/31/2022 12:30:47 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:SISKIYOU (SCOE) INFANTFACILITY NUMBER:
475403887
ADMINISTRATOR:SMITH, KELLYFACILITY TYPE:
830
ADDRESS:1 CHILD'S WAYTELEPHONE:
(530) 842-8493
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:24CENSUS: 8DATE:
01/27/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nicole Whitlow & Chez GiertzTIME COMPLETED:
12:30 PM
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The facility pre-licensing inspection was conducted by Licensing Program Analyst’s (LPA) Snow. A change of rooms was submitted; the facility was operating in room B1, B2 & E and submitted an application to conduct care in rooms B1, B2 & D. The facility is adding a new play yard. The facility is keeping the capacity of 24 infants with a toddler component.

The LPA met with Nicole Whitlow & Chez Giertz the facility was toured inside and outside. The facility’s operating hours are 8:30am - 3:30pm, Monday-Friday year-round. The indoor and outdoor capacity measured for the requested capacity. Required postings (Parents Personal Rights, Emergency Disaster Plan, Earthquake Preparedness Checklist, Menu, etc.) listed on Form LIC 311A are posted. The program is run by a public entity and the background clearance is required through them prior to employment. The applicant is aware of the immediate $100 per day civil penalty for anyone providing care or supervision without a criminal record clearance.
The infants will use the fenced outdoor play area. Sign-In/Out procedure were reviewed. And the applicant understands that if a manual Sign-In/Out procedure is used; full legal signatures are required. There is a working carbon monoxide detector and charged fire extinguisher in the facility rated at least the 2A10BC. There are two toilets and two sinks watch in room B1 & B2, Room B has 3 sinks and all rooms have access to a separate staff bathroom. Water is available inside by use of water cups and outside via bottles and sippy cups.

Infants with symptoms of illness will not be accepted, and infants/toddlers who become ill during the day will be isolated in front staff office. The facility has sufficient cribs or mat/cot for each napping infant/toddler and bedding will be washed daily.

SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530)215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SISKIYOU (SCOE) INFANT
FACILITY NUMBER: 475403887
VISIT DATE: 01/27/2022
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Cribs will be free of loose objects. Infants will be supervised at all times while sleeping, and staff will physically check on sleeping infants every 15 minutes. The 15-minute checks will be documented on individual sleeping log and kept in the infant’s file. Infants under 12 months will be placed on their backs for sleep, and no infants will be swaddled, and the facility will have an Infant Sleeping Plan on file.

Breakfast, lunch and snack are provided at the program and a menu will be posted. Age appropriate toys and activities are available for infants/toddlers. There is rubber cushion material underneath the play structures sufficient to absorb falls in toddler and infant play yards. Shade is provided in the play yard. There are no bodies of water located on the property and none are to be added without prior notification and approval of the licensing agency. Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes 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. This report, as well as the Guide to Safe Sleep Practices brochure, Lead Exposure Testing and COVID Guidance were reviewed and discussed with the applicant/director. All licensing reports are public information and must be made available upon request for at least three years.


Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department
The facility is ready for licensure once the control of property has been submitted to Community Care Licensing.


Complete a new application form with original signature for a capacity of 24 with a toddler component.
New fire clearance shall be requested by CCL (showing room numbers and total capacity).
The file will be reviewed for completeness & director qualifications prior to approving the move.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530)215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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