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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419028
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:37:20 AM

Document Has Been Signed on 09/12/2024 11:37 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:EVANS, CAROLFACILITY NUMBER:
013419028
ADMINISTRATOR/
DIRECTOR:		EVANS, CAROLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 600-0108
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Carol Evans TIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On September 12, 2024 at approximately 09:30 AM, Licensing Program Analyst, (LPA) Lorraine Dacanay Breaux made an unannounced 1 year required inspection. LPA Dacanay Breaux met with Licensee, Carol. Evans present for the inspection was licensee, and licensee's fingerprint cleared mother, and father. LPA was granted entry and provided LIC 126. There were nine (9) children, 4 infants, 3 toddlers and 2 school age children in care during todays inspection. Hours of Operation are Monday - Saturday 7: 00 AM - 6:00 PM.

This is a two story home with four (4) bedrooms and 3 bathrooms. The facility was toured inside and outside for health and safety. The home is neat and clean, with heating and ventilation for safety and comfort.
ON LIMITS AREA: Family room, dining room, first floor bathroom, kitchen, living room, and backyard. OFF LIMIT AREAS: One bedroom on the lower level, entire second floor upstairs which includes master bedroom and bathroom/deck, two additional bedrooms and two bathrooms, and the attached garage. Outdoor Play Area: The rear yard and is fully fenced. There are no pools, hot tubs, or any other bodies of water present in the on-limit areas during today’s inspection. ISOLATION AREA: Living room away from the children in care. There is a child gate at the bottom of the stairs preventing children from accessing the upstairs areas. Per licensee she resides in the home. Licensee confirmed there are no swimming pools/bodies of water at the home during today's visit. Per licensee there are no firearms. Per licensee she does provide transportation, LPA reviewed licensee's driver's licenses and it is current. LPA reminded licensee that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping. The licensee states that she does not administer medication to the day care children during this time.

The home has a working smoke detector, carbon monoxide detector (tested/functioning) on the main level, fully charged 3A40BC fire extinguisher located in the kitchen, working telephone and fully stocked first aide kit. LPA observed a barricaded fireplace in the family room. All hazardous materials and toxins are kept out of reach from children and are not accessible.

809-C
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 09/12/2024
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LPA reviewed CPR/First Aid certification expires on 11/26/24. The licensee completed the mandated reporter training on 12/31/2023. Licensee is reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years for all employees/volunteers working in the child care home. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 08/19/2024. All required forms are posted and visible for public review.

LPA discussed the requirements according to Title 22 for overnight care with licensee, since the licensee stated that she provides occasionally (as needed) overnight care. LPA discussed and provided Title 22 Regulation #102426 to licensee for review.

Records: At 10:20AM LPA Dacanay Breaux reviewed four (4) children’s files and personnel records. Individual Infant Safe Sleep Plans (LIC 9227) are complete and in child's file. LPA reviewed Sleep Charts for sleeping infants and are within compliance of the Safe Sleep Regulations. There is a current roster available for review and LPA obtained a copy. The facility does have liability insurance and LPA reviewed expires on 06/14/2025.


Criminal Record Clearance: Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Safe Sleep: 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-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

LIC 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: EVANS, CAROL
FACILITY NUMBER: 013419028
VISIT DATE: 09/12/2024
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Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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/resources/child-care-centers/.

MyChildCarePlan.org: Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

CCLD Inspection Process: To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Megan’s Law: During the exit interview, licensee, Carol Evans confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

No deficiencies nor advisory notes issued during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights Provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Carol Evans.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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