485408096-5-6-2022-13-CC-KMAS-CE6RJ4-20220506130319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 485408096
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:03:25 PM

Document Has Been Signed on 05/06/2022 01:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SCZEPANSKI, LACY FAMILY CHILD CARE HOME		FACILITY NUMBER:	485408096
ADMINISTRATOR:	SCZEPANSKI, LACY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 628-8925
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	14	CENSUS:	DATE:	05/06/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Licensee, Lacy Sczepanski		TIME COMPLETED:	01:15 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	A prelicensing inspection was conducted today at 12:15pm by Licensing Program Analysts (LPA), Kirk Marks and Jackie Helton. LPAs met with licensee Lacy Sczepanski. The licensee is requesting a change of location license for a capacity of 14. The facility will operate Monday-Friday, 7:00am to 5:00pm. The residence is a four bedroom/3 1/2 bath two story home. There is one adult and four minors currently living in the home. The home and yard were toured, and the facility sketch was verified. The following areas will be off limits to children: Entire upstairs which includes three bedrooms, two bathrooms and a laundry room and one bedroom and bathroom downstairs, as well as the garage. These areas have been made inaccessible by means of safety gates and safety door knob stops. Poisons are not kept in the home. The home is equipped with a working smoke detector and fire extinguisher rated at least 2A10BC. The children will use the backyard as the outdoor play area. The backyard is completely fenced; however the backyard is currently under construction and not currently used for play. The licensee currently walks children to a nearby park for outdoor play until the back yard is completed. Licensee understands that constant supervision must be provided while children are at the park. There is no pool, spa, pond, fountain, or any other body of water on the premises. LPA reviewed with licensee representative the LIC 311D, Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Kirk Marks	TELEPHONE: (530) 895-5045
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SCZEPANSKI, LACY FAMILY CHILD CARE HOME	FACILITY NUMBER: 485408096
	VISIT DATE: 05/06/2022

NARRATIVE

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Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant/licensee/facility representative 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Kirk Marks	TELEPHONE: (530) 895-5045
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC809 (FAS) - (06/04)

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