490170168-2-16-2022-01-CC-JVEO-CBPU5K-20220216141653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490170168
Report Date: 02/16/2022
Date Signed: 02/16/2022 02:18:53 PM

Document Has Been Signed on 02/16/2022 02:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CARLSON, DEBORAH FAMILY CHILD CARE HOME		FACILITY NUMBER:	490170168
ADMINISTRATOR:	CARLSON, DEBORAH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 573-3703
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	14	CENSUS: 6	DATE:	02/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Deborah Carlson		TIME COMPLETED:	12:40 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 of the facility was conducted by Licensing Program Analyst, Jennifer Velasco (LPA), who met with Licensee Deborah Carlson (L1). A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. L1 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. During today’s inspection the home and grounds were toured. L1 was supervising six children under 10 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 7:30 a.m. - 5:00 p.m., Monday - Friday, year-round. The floor plan submitted by L1 was reviewed and verified. Care is provided in the converted garage, hall bathroom, and fenced side yard. Occasionally, care is provided in the kitchen/family room area. The off-limits areas of the home are the bedrooms, master bathroom, office, formal living room, backyard, enclosed deck, and two inaccessible storage sheds. These were made inaccessible by use of key and combination locked doors, fencing, and padlocked 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. L1 stated there is a working telephone in the home. L1’s and staffs' pediatric CPR and First Aid certifications were reviewed and expire in 09/2023. 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 a locked cupboard in the kitchen. Licensee stated and LPA verified that poisons are inaccessible in a key locked shed in the inaccessible portion of the yard.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLSON, DEBORAH FAMILY CHILD CARE HOME	FACILITY NUMBER: 490170168
	VISIT DATE: 02/16/2022

NARRATIVE

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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. L1 has conducted an emergency drill within the past six months; the last drill was documented in 01/2022. L1 stated there are no firearms or other weapons in the home, and none were observed during this inspection. There were no pools or other bodies of water. Children use the fully fenced, partially shaded side yard as an outdoor play space. Six children's records were reviewed at 10:30 a.m., and files contained current immunizations and/or medical exemptions, as well as Parents' Rights Notifications, as required. Facility files were reviewed, and licensee and staff immunization and certification records were on file as required. Though L1 stated she does not provide care to infants, LPA and L1 discussed the safe sleep regulations and 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 L1 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. 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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with L1. There were no Title 22 deficiencies cited during today's inspection. 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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC809 (FAS) - (06/04)

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