013423888-9-1-2023-02-CC-AAKE-CV9NWM-20230901104947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423888
Report Date: 09/01/2023
Date Signed: 09/01/2023 10:49:53 AM

Document Has Been Signed on 09/01/2023 10:49 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	BALICKI, MARY-ETTA		FACILITY NUMBER:	013423888
ADMINISTRATOR:	MARY-ETTA BALICKI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 801-5865
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94618
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	09/01/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Mary-Etta Balicki		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/01/2023, at 8:30am, Licensing Program Analysts (LPAs) Ashley Akinleye and Christina Watts conducted an announced prelicensing inspection. Present for the inspection was the Applicant, Mary-Etta Balicki, her husband, Cheney Munson and assistant, Caitlin Gibbs. Residing in the home is the Applicant, her husband and dog. The home was toured for a health and safety inspection. Operating hours will 8:30am-4:30pm, Monday through Friday. The house is three story home. There are five bedrooms and two and a half bathrooms, which are neat and clean with heating and ventilation for the children. The entrance to the day care is the left side of the home, near garage and will only be used for the entrance and exiting of children and their parents. The inside and outside of the home were observed to be neat, clean with age-appropriate materials and toys for the children. During today’s inspection, LPAs did not observe any hazards. Licensee has stated that there are no firearms in the home. ON LIMIT AREAS: Three ground floor rooms(main area used for daycare/entrance), one bathroom on first floor, and entire backyard OFF LIMIT AREAS: The entire second floor, One bedroom, a half bathroom and the kitchen, which is closed off by a fence/small gate on the first floor. ISOLATION AREA: napping area (one bedroom on ground floor) The home has working smoke detectors and carbon monoxide in the on limits bedrooms, fire extinguisher (3A40BC) and a working telephone. LPAs did not observe any bodies of water in or around the home. There is one pet on the property. Report continues on 809C

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BALICKI, MARY-ETTA	FACILITY NUMBER: 013423888
	VISIT DATE: 09/01/2023

NARRATIVE

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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.

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

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.

Report continues on 809C

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BALICKI, MARY-ETTA	FACILITY NUMBER: 013423888
	VISIT DATE: 09/01/2023

NARRATIVE

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Licensee was informed of the MyChildCarePlan.org site, 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.

LPA reviewed with licensee the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Entrance Checklist was provided to the applicant.

On this date, 07/06/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Mary-Etta Balicki provided proof of control of property. Because the applicant leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Fire inspection approved by Oakland Fire Department on 7/31/23.

Exit interview conducted with Mary-Etta Balicki and Caitlin Gibbs.

License effective as of 09/01/2023

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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