483004319-5-2-2019-01-CC-MAUN-BBSS32-20190502133026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483004319
Report Date: 05/02/2019
Date Signed: 05/02/2019 01:30:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	HOLLAND, SHARI FAMILY CHILD CARE HOME		FACILITY NUMBER:	483004319
ADMINISTRATOR:	HOLLAND, SHARI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 655-2556
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	14	CENSUS: 5	DATE:	05/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:49 AM
MET WITH:	Donna Bassett & Shari Holland		TIME COMPLETED:	01:45 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/Random inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 05/02/19 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 currently three adults living in the home. During today’s inspection the home and grounds were toured. The licensee and two assistants (S1 & S2) were supervising five 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 6am to 6pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire upper level of the home, three bedrooms on the lower level, backyard and the garage, and were made inaccessible by a child safety gate and door locking mechanisms. The home was observed to be clean and orderly, and was at a comfortable indoor temperature of 77 degrees Fahrenheit. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed, and expire on 10/2020. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. LPA did not observe any poisons. The staircase near the lower level hallway bathroom is barricaded with a child safety gate. The fireplace has been made inaccessible with a screen. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 11/14/18. S1 stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

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,
, CA

FACILITY NAME: HOLLAND, SHARI FAMILY CHILD CARE HOME	FACILITY NUMBER: 483004319
	VISIT DATE: 05/02/2019

NARRATIVE

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The backyard is off limits. The licensee said the children use the local community park as the outdoor play area. There were no pools or other bodies of water observed. Two children's records were reviewed at 12:31pm; current immunizations and Notification of Parent’s Rights forms were on file. The licensee is not providing Incidental Medical Services (IMS) to children in care. 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 and The Effects of Lead Exposure brochures, 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.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

LIC809 (FAS) - (06/04)

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