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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421507
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:47:51 PM

Document Has Been Signed on 07/30/2024 01:47 PM - 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JOHNSON, DEBRAFACILITY NUMBER:
013421507
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Debra JohnsonTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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On July 30, 2024, at 9:00 AM, Licensing Program Analyst (LPA) Janai McClain arrived at the home for an unannounced Annual Inspection. LPA met with the licensee Debra Johnson. Present during the inspection were one infant and three preschool age children in care. Licensee stated that the facility operates from Monday through Friday 6:00 AM to 6:00 PM.

LPA toured the facility to conduct a Health and Safety inspection. The facility is a one story home with two bedrooms and one bathroom, which was observed to be neat and clean, with heating and ventilation for the safety and comfort of children in care. The Isolation area is the couch in the living room.

On Limit areas: Living room, dining room, play room, and bathroom.

Off- Limit areas: kitchen and bedroom on the right

The off-limit areas will be made inaccessible by gates, closed and/or locked doors and visual supervision. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. There are ample age appropriate toys that appear to be safe and in good condition.

The home has a fully charged 3A40BC fire extinguisher, a working carbon monoxide detector, and telephone. The licensee is reminded to test the smoke detector to ensure that it is working properly. There’s a wall heater in the living room that is blocked to prevent access. The fireplace is sealed and gated.
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SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JOHNSON, DEBRA
FACILITY NUMBER: 013421507
VISIT DATE: 07/30/2024
NARRATIVE
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The facility is operating within its licensed capacity and is in ratio. The licensee's CPR & First Aid training expired 7/20/2024. The Licensee's Mandated Reporter certificate expired on 6/16/2024. The licensee is reminded to conduct fire/disaster drills every 6 months.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

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

Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
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SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JOHNSON, DEBRA
FACILITY NUMBER: 013421507
VISIT DATE: 07/30/2024
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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.

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 platforms. 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

There was one Type B deficiency cited during today's visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted.

Report and Appeal Rights were reviewed with the Licensee Debra Johnson.

******************************************** End of Report **************************************

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 01:47 PM - It Cannot Be Edited


Created By: Janai McClain On 07/30/2024 at 01:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JOHNSON, DEBRA
FACILITY NUMBER: 013421507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 smoke detectors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee will change batteries in the smoke detector and send LPA a video of the detector being tested by 8/13/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Janai McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


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