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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111872
Report Date: 10/21/2019
Date Signed: 10/21/2019 10:10:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:WOOD-SHAW, JANET FCCHFACILITY NUMBER:
490111872
ADMINISTRATOR:WOOD-SHAW, JANET FCCHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 795-8568
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:14CENSUS: 7DATE:
10/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Janet WoodTIME COMPLETED:
10:20 AM
NARRATIVE
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An unannounced inspection of the facility was conducted by Licensing Program Analyst (LPA) J. Velasco. A review of staff records prior to this inspection indicates that all facility staff and 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. The licensee and an assistant were supervising seven child under ten years of age and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:00 a.m. - 6:00 p.m., Monday - Friday, year-round. The floor plan submitted by the licensee was reviewed and verified. Child care is provided in two large playrooms, a kitchenette, and a bathroom. The fenced backyard is the outside play area. The off-limits areas of the home are the key locked garage, the unfenced portions of the site, locked outbuildings, and the bedrooms, bathrooms, and main living areas of the home. These were made inaccessible by use of key locked doors, fencing, and gates. 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 expired. 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 in the inaccessible utility room. Licensee stated and LPA verified that poisons are inaccessible in a key locked cupboard in the inaccessible utility room.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WOOD-SHAW, JANET FCCH
FACILITY NUMBER: 490111872
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2019
Section Cited

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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid. This standard has not been met as evidenced by:
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 LPA’s 10/21/19 observation at 9:30 a.m. that neither licensee (L1) nor assistant (S1) has proof of current CPS/1st Aid certification. This is a potential health and safety risk to children.
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Fax: 707-588-5099
Email:
jennifer.velasco@dss.ca.gov
Type B
11/22/2019
Section Cited

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The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement was not met as evidenced by: LPA's observation at 9:00 a.m. on 10/21/19 that children's files were
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 incomplete as follows: files for four children (C1-C4) were missing LIC 700, LIC 995E, and PM 286. This is a potential health and safety risk to children.
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Fax: 707-588-5099
Email:
jennifer.velasco@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: WOOD-SHAW, JANET FCCH
FACILITY NUMBER: 490111872
VISIT DATE: 10/21/2019
NARRATIVE
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Continued from LIC 809.


LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months; the last drill was documented in 07/2019. The licensee stated there are no firearms or other weapons in the home, and none were observed during this inspection. Children use the fully fenced, partially shaded backyard as an outdoor play space. Four children's records were reviewed at 9:00 a.m., and files contained current immunizations and/or medical exemptions, as well as Parents' Rights Notifications, as required. Facility files were reviewed at 9:30 a.m., and licensee records were on file.

The licensee does not currently provide Incidental Medical Services (IMS) to children in care. Licensee plans to provide the Department with a Plan of Operation if needed. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, 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. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809-D. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3