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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573621940
Report Date: 07/31/2019
Date Signed: 07/31/2019 01:37:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GOLAY, ASHLEEFACILITY NUMBER:
573621940
ADMINISTRATOR:GOLAY, ASHLEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 219-6879
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:14CENSUS: 8DATE:
07/31/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Ashlee GolayTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Seychelle De Luca met with Licensee Ashlee Golay for the purpose of an unannounced annual random inspection. Licensee's mother was also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the master bedroom/bathroom, last bedroom, library, laundry room, dog run, and garage. LPA observed the required postings, a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. The fireplaces are appropriately barricaded to prevent access by children and outdoor play space is fenced.

Five children’s files were reviewed. LPA observed immunization records and signed Family Child Care Home Notification of Parents' Rights in children's files. A current roster is being maintained and fire and disaster drills are documented. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified for Licensee and Licensee's mother and expires 04/13/2021 and AB 1207 Mandated Reporter Training was verified and expires 09/11/2020.

This provider is currently not providing IMS services to children in care. 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.

Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: 916-217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GOLAY, ASHLEE
FACILITY NUMBER: 573621940
VISIT DATE: 07/31/2019
NARRATIVE
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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 verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so Licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed the Safe Sleep Environment, Safe Sleep in Child Care, and Effects of Lead Exposure brochures. LPA provided new blue immunization card.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form.



Title 22 deficiencies are cited on the subsequent pages of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: 916-217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GOLAY, ASHLEE
FACILITY NUMBER: 573621940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home - Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by LPA observing yard tools, shovels, lawn mower, and rotary tiller
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Licensee moved the tools, lawn mower, and tiller to the garage. Licensee will send LPA pictures to prove the broken patio areas have been covered or barricaded to prevent possible tripping hazards. Licensee will send these pictures by POC date: 8/1/2019.
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in the backyard. LPA also observed several outdoor patio tiles have been removed and pose potential tripping hazards. This poses an immediate health and safety concern to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: 916-217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2019
LIC809 (FAS) - (06/04)
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