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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009990
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:16:39 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:MILLER, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 416-8396
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:14CENSUS: 7DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Kimberly MillerTIME COMPLETED:
02:33 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. A review of staff records on 10/01/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index. clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. There are currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee was supervising five children. The facility’s operating hours are 07:30am to 05:30pm, Mon–Thur and 07:30am-04:00pm. 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 room, living room, kitchen, children's playroom, downstairs bathroom, and bedroom. The garage and the home's second floor are off-limits and inaccessible and the staircase leading to the second floor is gated. The wood burning fireplace in the children's playroom is screened; licensee stated that it is not used. 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 August 2023. The licensee's CA mandated reporter training certificate expires June 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 there are no poisons or firearms and ammunition stored on the premises. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The children use the home’s backyard as the outdoor play area; it is fully fenced and there were no bodies of water observed. Four children's records and two staff records were reviewed during today's inspection. LPA reviewed infant safe sleep logs and infant safe sleep plans (LIC 9227) with the licensee. This facility is in compliance with new safe sleep regulations.
Continued on LIC 809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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: MILLER, KIMBERLY FCCH
FACILITY NUMBER: 483009990
VISIT DATE: 10/01/2021
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Other links to resources were provided as well.

Incidental Medical Services (IMS) policy was discussed. 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 (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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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