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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566206478
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:21:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KISSICK FCC AKA CAMP KISSICKFACILITY NUMBER:
566206478
ADMINISTRATOR:BRENDA I. KISSICKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 373-1486
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:14CENSUS: 10DATE:
10/16/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Brenda KissickTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual Random inspection. LPA met with licensee Brenda Kissick and advised her the purpose of the the inspection. LPA and licensee together the facility inside and out. Licensee has a six bedroom home. There was 10 children in care at the time of the inspection.

Licensee uses three bedrooms, a sun room, one restroom, and the back yard for care. The children are mainly cared for in the sun room and back yard. Licensee stated that she does not have fire arms and/or ammunition in the home. LPA observed a fireplace with a glass screen located in the family room. There are age appropriate toys and furniture readily accessible for children in care. A 2A10BC fire extinguisher was observed mounted on the wall in the sun room with a last service date of 05/23/19. LPA observed functioning smoke and carbon monoxide detectors tested by the licensee. The backyard is fully enclosed with wood fence. Licensee has age appropriate toys and play structure in the backyard readily accessible to children. Parts of the back yard are sectioned off for licensee's live tortouis. There is another section where licensee has a stored motor home. Continued on 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KISSICK FCC AKA CAMP KISSICK
FACILITY NUMBER: 566206478
VISIT DATE: 10/16/2019
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A roster of children in care was observed current and complete. A sampling of children records was reviewed and found current. LPA verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Licensee does not have liability insurance for their facility. A liability insurance waiver was observed in each child's file. First-Aid and CPR is current until 03/03/21. Mandated Reporter training is current until 09/20/18. The Fire/Emergency drill was completed on 09/13/19. LPA discussed Incidental Medical Services (IMS) with licensee. Licensee currently does not have children in care that require IMS. LPA discussed and provided licensee AB 2370 Lead Exposer guide and Safe Sleep pamphlet.

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 (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

No deficiencies were cited during today's visit.



THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
LIC809 (FAS) - (06/04)
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