490170204-8-26-2021-01-CC-JVEO-C69T3E-20210826142215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490170204
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:23:26 PM

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:	CLARK, CHARLOTTE FAMILY CHILD CARE HOME		FACILITY NUMBER:	490170204
ADMINISTRATOR:	CLARK, CHARLOTTE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 763-3683
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	14	CENSUS: 3	DATE:	08/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Charlotte Clark and Cindy Clark		TIME COMPLETED:	11:10 AM

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 required annual inspection of the facility was conducted by Licensing Program Analyst (LPA), J. Velasco. 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. There are currently three adults living in the home. During today’s inspection the home and grounds were toured. Licensee (L1) was present in the home. Licensee Charlotte Clark (L1) and staff Cindy Clark (S1) were supervising three children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 6:00 a.m.--6:00 p.m., Monday–Friday, year round. The floor plan submitted by the licensee was reviewed and verified. The children have access to the kitchen/dining area, living room, hall bathroom, three bedrooms, and fully fenced backyard. The off-limits areas of the home are the garage, hallway closets, backyard sheds, and side yards, which were made inaccessible by locked gates and key locks. 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. There is a working telephone in the home. There is a fireplace in the living room, made inaccessible by a locking gate. L1's and S1's pediatric CPR and First Aid certifications were reviewed and expire in 01/2023. 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 the locked garage and upper kitchen cupboards. S1 stated there are no poisons in the facility and if there were any poisons, they would be kept in a key locked cupboard in the key locked garage. The home is heated and cooled by a central unit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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,
, CA

FACILITY NAME: CLARK, CHARLOTTE FAMILY CHILD CARE HOME	FACILITY NUMBER: 490170204
	VISIT DATE: 08/26/2021

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 emergency drill was documented in 08/2021. S1 stated there are no guns on premises, and none were observed during this inspection. The children use the backyard as the outdoor play area, and the property is fully fenced. S1 stated there were no pools or other bodies of water, and none were observed. Five children's records were reviewed at 10:00 a.m., and current immunizations and Notification of Parent’s Rights forms were on file. Facility and personnel files were reviewed at 10:20 a.m. and contained necessary records. The licensee is not currently providing Incidental Medical Services (IMS) to children in care. 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. There were no Title 22 deficiencies cited during today's inspection. Notice of Site Visit shall be posted for 30 days from today's visit.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

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