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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008960
Report Date: 08/27/2019
Date Signed: 08/28/2019 05:41:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HANSEN, JENNIFER FCCHFACILITY NUMBER:
493008960
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
08/27/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Jennifer HansenTIME COMPLETED:
01:38 PM
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A case management inspection was conducted today by Licensing Program Analyst (LPA) Y. Yang in response to an increase of capacity application received 08/05/19. The licensee is requesting a capacity of 14. The licensee has met the required experience for a large family child care home. The approved fire clearance was received on 08/27/19 for the requested capacity. 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 presently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee was properly supervising six children. Operating hours are 7:30am to 5:30pm, Mon–Fri. The master bedroom and bathroom, bedroom #2, laundry room, and garage are off-limits. The off-limits rooms were made inaccessible with door knob covers and/or door locks. Licensee understands that off-limits areas shall be made inaccessible at all times during child care hours. The living room, dining room, kitchen, hall bathroom, and bedroom 1 are on-limits. The fireplace has been made inaccessible with a glass screen. The children will use the home's backyard as the outdoor play area and it is fully fenced. Licensee stated there are no poisons, firearms, or other dangerous weapons stored on the premises. There were no pools or other bodies of water observed on the premises. The licensee's pediatric CPR and First Aid expire 10/10/20. Ratios for a large family child care home were reviewed. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a working smoke detector, carbon monoxide detector, and charged fire extinguisher rated 2A:10B:C in the home.

(Continued on LIC 809-C)
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HANSEN, JENNIFER FCCH
FACILITY NUMBER: 493008960
VISIT DATE: 08/27/2019
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The licensee is not providing Incidental Medical Services – IMS. 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 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 reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.
Notice of Site Visit shall be posted for 30 days from today's visit.
There were no Title 22 deficiencies cited during today's inspection. The increase of capacity is granted effective 08/27/19.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019
LIC809 (FAS) - (06/04)
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