<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009990
Report Date: 10/12/2020
Date Signed: 10/12/2020 04:20:53 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:MILLER, KIMBERLY FCCHFACILITY NUMBER:
483009990
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
10/12/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kim MillerTIME COMPLETED:
12:00 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
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.

LPA Ouye conducted a tele-visit prelicensing inspection due to a change of location and a capacity increase. The licensee submitted the change of location and capacity increase application on September 24, 2020. The fire inspection was conducted by the Fairfield Fire Department and received by the department on October 12, 2020. The licensee is qualified to operate as a large FCCH based on her years of experience operating a small FCCH.

The licensee toured LPA Ouye though the interior and exterior of the home. The licensee verified that the smoke detector and carbon monoxide detectors are present and functioning. There is a fire extinguisher rated at least at 2A10BC and the installed pull station which was tested and functional. The licensee has her covid-19 protocols in place as she did in the home which she is vacating. The licensee stated that there are no poison and no weapons in the home. The licensee has age appropriate toys and equipment available for the children in care. The upstairs floor of the home is off limits and is made inaccessible with a child safety gate.

The outdoor area was viewed by LPA. It is completely fenced. No bodies of water were observed during the visit and the licensee confirmed that there are no bodies of water.

The licensee has met the requirements and is approved to operate as a large FCCH effective October 12, 2020.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
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 1