483009902-7-15-2021-01-CC-YYAG-C4XVA5-20210715161521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009902
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:15:27 PM

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:	07/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Stacy Bouchard		TIME COMPLETED:	03:02 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 required inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. A review of staff records on 07/15/2021 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 is currently one adult living in the home. During today’s inspection the home and grounds were toured. There were no children present at the facility. The facility’s operating hours are 10:00am to 02:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home were made inaccessible by door locks and/or child gates. The children have access to the home's dining area, living room, kitchen, and hall bathroom. The garage and all bedrooms are off limits and inaccessible. The home was observed to be clean and orderly, and was at a comfortable indoor temperature. 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 in February 2022. 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. The licensee stated that she currently does not have any poisons stored at the facility. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The wood burning stove in the living room is screened and barricaded. Licensee stated that it is not used during childcare hours. The licensee stated that firearms and ammunition are not stored on the premises. The children use the home’s backyard as the outdoor play area. It is fully fenced and there were no bodies of water observed. No children's files were reviewed today. The licensee currently does not have any children enrolled. Continued on LIC 809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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: 07/15/2021

NARRATIVE

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The licensee currently does not have any children in care requiring 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 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,The Effects of Lead Exposure brochure, and COVID guidelines and best practices 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: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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