503607005-3-18-2020-04-CC-AMEA-BMTSH7-20200318135305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 503607005
Report Date: 03/18/2020
Date Signed: 03/18/2020 01:53:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	BUTCHER, TRACI		FACILITY NUMBER:	503607005
ADMINISTRATOR:	BUTCHER, TRACI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 521-6067
CITY:	MODESTO	STATE: CA	ZIP CODE:	95358
CAPACITY:	14	CENSUS: 6	DATE:	03/18/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Traci Butcher		TIME COMPLETED:	02:00 PM

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On 03/18/2020, Licensing Program Analyst (LPA) Angelica Mejia conducted an unannounced Required 1-Year inspection and met with Licensee Traci Butcher. Also present was Assistant Blanca. LPA explained the reason for the inspection, conducted a tour of the home both inside and outside, and a census was taken.

The rooms accessible to children in care are: bedroom #1, bathroom, living room, kitchen, dining room and back yard. Off-limits rooms are made inaccessible via plastic doorknob spinners and locks. Licensee has one bird; Licensee understands the liability and safety of children around pets and accepts responsibility. There are no "bodies of water" on the premises. Firearms and ammunition are properly stored. No poisons were observed on the premises. Cleaning compounds, medications and other hazardous items are inaccessible to children. Fireplace is screened and inaccessible to children in care. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment were observed.

There is a working telephone and the number was verified. Adequate supervision is being provided during this inspection. Capacity as specified on the license is being maintained. Licensee has a current roster of the children and maintains emergency information and forms as required. A review of records indicates that immunization records are on file for children and adults. Licensee has provided parents with a copy of the Family Child Care Home Notification of Parent's Rights (LIC 995A). Fire/disaster drills are conducted every six months and documented; the last drill was conducted on 03/02/2020. Licensee is aware that children are never to be left in parked vehicles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present in the home. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care.

(Continued on LIC809-C)

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Angelica Mejia	TELEPHONE: (559) 341-6126
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2020

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: BUTCHER, TRACI	FACILITY NUMBER: 503607005
	VISIT DATE: 03/18/2020

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Pediatric CPR/First Aid is current and expires 06/06/2020. Mandated Reporter training AB 1207 is current for Licensee and all staff. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. Postings such as Emergency Disaster Plan, Earthquake Preparedness checklist, facility license and notification of parent’s rights poster are posted on entry wall. Days and hours of operation are Monday – Friday, 07:00 AM – 05:00 PM, and as arranged.

This facility provides Incidental Medical Services (IMS). Licensee does not have any children currently enrolled that require IMS. 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

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov, Provider Information Notices (PINS), Quarterly Updates, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Unusual Incident Reporting, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited.

An exit interview was conducted with Licensee and a copy of this report was provided and discussed.

This report shall be made available to the public upon request. Notice of Site Visit (LIC9213) is required to be posted for 30 days.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Angelica Mejia	TELEPHONE: (559) 341-6126
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2020

LIC809 (FAS) - (06/04)

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