490170204-7-14-2022-01-CC-JVEO-CGBT4E-20220714142349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490170204
Report Date: 07/14/2022
Date Signed: 07/14/2022 02:24:38 PM

Document Has Been Signed on 07/14/2022 02:24 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:	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: 10	DATE:	07/14/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cindy Clark		TIME COMPLETED:	12:30 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 case management inspection of the facility was conducted by Licensing Program Analyst (LPA) Jennifer Velasco for the purpose of adding applicant Cindy Clark (L2) as a co-licensee. 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 residing in the home. During today’s inspection the home and grounds were toured. The licensee (L1) and L2 and an assistant were supervising ten children and operating within 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 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 clean and orderly and was at a comfortable indoor temperature. There is a working telephone in the home. L2 has current pediatric CPR and First Aid certification, which expire in 2023. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. L2 stated there are no guns or other dangerous weapons in the home, and none were observed. L2 stated no poisons are stored on site. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The facility has a current roster of children in care. LPA reviewed licensing forms and unusual incident procedures. The licensee and applicant/assistant conducted an emergency drill within the past six months. The last drill was documented 06/2022. The backyard is used for outdoor play and is completely fenced. There are no bodies of water on the premises. L1 is not providing Incidental Medical Services (IMS) to children in care. IMS policy was discussed with L2. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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: CLARK, CHARLOTTE FAMILY CHILD CARE HOME	FACILITY NUMBER: 490170204
	VISIT DATE: 07/14/2022

NARRATIVE

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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 was discussed and reviewed with L1 and L2. All licensing reports are public information and must be made available upon request for at least three years. L2 has been granted an exception for the experience requirement as a licensee due to her several years' experience in child care and thereby meets licensing standards. L1 is thus added as a co-licensee effective 07/14/2022. 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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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