525407520-5-16-2019-13-CC-CKRD-BC8ME5-20190516093210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525407520
Report Date: 05/16/2019
Date Signed: 05/16/2019 09:32:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	MEDINA, ELIZABETH FAMILY CHILD CARE HOME		FACILITY NUMBER:	525407520
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/16/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Elizabeth Medina		TIME COMPLETED:	09:40 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 prelicensing inspection was conducted today by LPA, Chris Krogstad. The applicant is requesting a license for a capacity of 8. Services will be provided Mon-Fri, 6am-7pm. The residence is a three bedroom, 2 bath, two-story home. There are three adults and one minor living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. Children will have access to the living room, and down stairs master bedroom and bath. Toiletry items in the master bathroom need to be made inaccessible. The upstairs is off-limits and barricaded with a gate at the bottom of the staircase. The kitchen is off-limits with a gate in the entry way. Poisons in the laundry room and garage need to be locked. The home was clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. The applicant stated there are no firearms and no ammunition stored on site and none were observed. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2A10BC. Children will play in the fully fenced front yard. The lighter fluid, propane tank and paint need to be inaccessible and locked. There were no bodies of water observed. The side and backyard are off-limits and inaccessible with gates and the gate in the entryway of the kitchen. The applicant intends to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

SUPERVISOR'S NAME: Erin Virrueta	TELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Christen Krogstad	TELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MEDINA, ELIZABETH FAMILY CHILD CARE HOME	FACILITY NUMBER: 525407520
	VISIT DATE: 05/16/2019

NARRATIVE

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Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property/Landlord consent is needed. Parent's rights poster is posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current on Pediatric CPR and First Aid as well as Mandated Reporter Training. The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current Pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in those areas where childcare is provided.

The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/. Megan's Law web site was provided (http://www.meganslaw.ca.gov). The licensee understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. This report was reviewed and discussed with the applicant. Guide to Safe Sleeping Practices pamphlet was discussed.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

The following needs to be submitted to the department prior to the issuance of the license:

1. Negative TB test for all adults residing in the home
2. Propane tank, paint and lighter fluid in front yard need to be inaccessible and locked (key or combination)
3. Landlord consent from applicant's parents that live in the home
4. Poisons in laundry room and garage need to be locked
5. Proof of completed orientation
6. Copy of IMS Plan of Operation (medical policy in contact)
7. Toiletry items in the master bathroom need to be made inaccessible.

SUPERVISOR'S NAME: Erin Virrueta	TELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Christen Krogstad	TELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

LIC809 (FAS) - (06/04)

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