503911783-5-2-2022-04-CC-RMAS-CE2NCM-20220502102057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 503911783
Report Date: 05/02/2022
Date Signed: 05/02/2022 10:21:03 AM

Document Has Been Signed on 05/02/2022 10:21 AM - 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GOSS, ASHTYN FAMILY CHILD CARE		FACILITY NUMBER:	503911783
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ashtyn Goss		TIME COMPLETED:	10:30 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	On 05/02/2022 a planned Pre-licensing/Change of Location/Increase Capacity inspection was made today by Licensing Program Analyst (LPA) Rene Mancinas, who met with Licensee, Ashtyn Goss. A tour of the home, inside and outside, as shown on the facility sketch was done. This is a single-story home. The areas of the home that day-care children will have access to are the daycare room, hallway restroom, kitchen, family room, and a portion of the backyard designated for day care use. The remainder of the home is off limits and made inaccessible by child safety devices (i.e. safety latches and/or plastic doorknob spinners and/or safety gates). Licensee and one other adult reside in the home. The LIS 536 was signed indicating that the adults living in the home and/or providing care and supervision to children are background cleared. LPA observed safe indoor play areas, child safety plugs in unused electrical outlets, were all observed. Fire extinguisher, smoke detectors, carbon monoxide detectors and first aid kit are operable and in place. There are no firearms or ammunition at this home. There are no swimming pools, ponds, fountains, or other bodies of water at this home. CPR, first aid training, and health and safety training are current and expiring 12/04/2023. Child Abuse Mandated Reporter Training Completed on 01/15/2022. LPA discussed the practice of fire and disaster drills at least every 6 months and to document the date, time and number of children present. There are no pets at this home. Incidental Medical Services (IMS) policy were 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 (Continued on 809-C)

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Rene Mancinas	TELEPHONE: (559) 341-4524
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOSS, ASHTYN FAMILY CHILD CARE	FACILITY NUMBER: 503911783
	VISIT DATE: 05/02/2022

NARRATIVE

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Licensee 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, 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed applicants 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

The home, grounds and equipment meet Chapter 3, Division 12, Title 22 of California Code of Regulations and adequate for licensure as a Large Family Child Care Home. Large Family Child Care Home Licensure, capacity of 14 children * ages under 18 years* to be granted, effective 05/03/2022. A fire clearance was granted by fire department with jurisdiction. Planned hours of operation are Monday through Friday from 05:00AM - 06:00PM, and as arranged.

Exit interview conducted and report was reviewed with the Licensee.
This report shall be made available to the public upon request.

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Rene Mancinas	TELEPHONE: (559) 341-4524
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

LIC809 (FAS) - (06/04)

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