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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423686
Report Date: 03/10/2022
Date Signed: 03/14/2022 01:18:13 PM

Document Has Been Signed on 03/14/2022 01:18 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:MATTHEWS, AYANAFACILITY NUMBER:
013423686
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ayana MatthewsTIME COMPLETED:
02:41 PM
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On 03/10/2022 at 01:00 PM Licensing Program Analyst(LPA), Arminder Singh conducted an announced Pre-licensing Inspection. LPA met with the Applicant, Ayana Matthews. Applicant resides in the home with her adult son.

Applicant applied for a Small Family Child Care Home with capacity for 8 children. Days and hours of operation will be Monday through Friday from 6:00 AM - 6:00 PM. Applicant has current Pediatric cardiopulmonary resuscitation (CPR) and First Aid. Applicant rents this property. Applicant has a working telephone in the home.(925-457-9409)

At 1:15 PM: LPA toured the indoor space of the home with the Applicant. The home is a unit (#111) located on the first floor of the Uptown Apartments. Access box is located at the main entrance lobby where the applicant can be called to get access into building. The home consist of living room, two bedrooms, two bathrooms, and kitchen.

IN USE AREAS: The living room and bathroom #1 located on the right side of home.

OFF LIMIT AREAS: Bedroom #2 located on the left side of living room, bathroom #2 located in bedroom #2, bedroom #1 located on the right side of the home, and kitchen.

CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MATTHEWS, AYANA
FACILITY NUMBER: 013423686
VISIT DATE: 03/10/2022
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The home is sanitary, safe and orderly, with central heating and ventilation for safety and comfort. LPA observed: fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors all over the home. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and out of reach of children. LPA reminded Applicants that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Applicants states there are no pets in the home. Applicant states there are no firearms and ammunition stored in the home.


Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children (front of living room towards the kitchen), supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MATTHEWS, AYANA
FACILITY NUMBER: 013423686
VISIT DATE: 03/10/2022
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LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

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: http://www.ada.gov/childqanda.htm



Exit interview conducted and report was reviewed with the applicant. 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 platform.

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.

This facility is recommended for licensing effective 03/10/2022.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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