483009902-7-3-2020-01-CC-GOUE-BR6PM3-20200703112540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009902
Report Date: 07/03/2020
Date Signed: 07/03/2020 11:25:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	BOUCHARD, STACY FCCH		FACILITY NUMBER:	483009902
ADMINISTRATOR:	BOUCHARD, STACY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 730-3089
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	14	CENSUS: 0	DATE:	07/03/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Stacy Bouchard		TIME COMPLETED:	10:30 AM

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	The facility inspection was conducted via tele-inspection due to the Covid-19 state of emergency pandemic. The department has suspended all field operations and the applicant has agreed to conduct the video conference with LPA, (Licensing Program Analyst) Glenn Ouye. A pre-licensing inspection was conducted today by Licensing Program Analyst (LPA) Glenn Ouye. The applicant submitted an application requesting a license as a large FCCH. Services will be available Monday - Friday 10:00 AM - 2:00 PM. The applicant’s operations will follow the school district calendar year. 24hr consecutive care is prohibited. The applicant will provide care for children 2 year The residence is a single story, four bedroom home. There is one adults living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The floor and yard plans are verified. The children will have access to the living room, dining room, kitchen, bathroom and backyard. All other area of the home are "off limits" to the day children. The inaccessible areas have been made inaccessible by a child safety gates. Latches are used on the kitchen drawers that contain sharps. The home appears to be clean and orderly at this time and will remain so during child care hours. The licensee will use a cell phone as the facility phone. Cleaning supplies, medicines, are inaccessible to children. The applicant does not have firearms in the home. The applicant has poisons locked in an outdoor shed. The regulation that poisons are to be locked using a key or combination lock is reviewed. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2A10BC. The fireplace in the family room is not used. There is a central heating/cooling unit. The children will use the back yard as the outdoor play area and it is completely fenced. There is no spa, pool, pond, or fountain.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn Ouye	TELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2020

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BOUCHARD, STACY FCCH	FACILITY NUMBER: 483009902
	VISIT DATE: 07/03/2020

NARRATIVE

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Incidental Medical Services regulations were reviewed with the licensee. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department.

Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Parent's rights are to be posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained and accessible to the department. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current pediatric CPR and First Aid certification. The applicant shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in any area where child care is provided. The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/. Megan's Law web site was provided (http://www.meganslaw.ca.gov). The Effects of Lead Exposure brochures were provided and reviewed with the applicant. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

This facility meets licensing standards and the application licensure is approved and goes into effect as of July 3, 2020.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn Ouye	TELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2020

LIC809 (FAS) - (06/04)

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