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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423929
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:29:18 AM

Document Has Been Signed on 05/09/2024 10:29 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:MATTHEWS, AYANAFACILITY NUMBER:
013423929
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ayana MatthewsTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 5/9/2024 at 9AM, Licensing Program Analyst (LPA) Brittany Crass, conducted an announced pre-licensing/change of location inspection and met with applicant Ayana Matthews. LPA disclosed the purpose of the inspection and was granted entry into the facility by the applicant. Residing in the home are the applicant, her fingerprint cleared son, and fingerprint cleared sister. The facility was toured to conduct a health and safety inspection. The applicant plans to operate Monday through Friday from 6AM-5:30PM, with evening drop ins as needed.

This home is a single story apartment building on the first floor of the complex consisting of four bedrooms, two bathrooms, a living room, dining room, kitchen, and a patio/balcony. The home was observed to be neat and clean with heating and ventilation for safety and comfort of the children.

On-limit-areas are: the bathroom to the left of the entryway, one bedroom used for the day care, the living room, and dining room.

Off-limit-areas are: three bedrooms, the bathroom in the main bedroom, and the kitchen, which are made inaccessible by closed and/or locked doors, gates, and visual supervision.

Outdoor play area: there is a fully fenced in patio/balcony which will be on-limits.

Isolation area: a section of the dining area.

There are age-appropriate toys which are observed to be safe, clean and in good repair. The applicant plans on providing meals and snacks. There are no bodies of water or pools accessible to children in care during today’s inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. Per applicant there are no firearms in the home. The applicant may provide Overnight Care, and plans on transporting children.

(see 809-C)

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: MATTHEWS, AYANA
FACILITY NUMBER: 013423929
VISIT DATE: 05/09/2024
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The home has a fully charged 2A10BC fire extinguisher in the kitchen, a working combination smoke/carbon monoxide detector in the front hallway, and a working telephone. The applicant’s CPR certificate expires on 12/15/2025 and the Mandated Reporter Certificate expires on 3/14/2026. The Applicant plans on having Liability Insurance.

The 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, 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.

The applicant rents and provided proof of control of property.

The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 children.

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) or (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 reviewed 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.

(see 809-C)

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MATTHEWS, AYANA
FACILITY NUMBER: 013423929
VISIT DATE: 05/09/2024
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LPA discussed the safe sleep regulations with the applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed the 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.

On, 1/4/24, 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.

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

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-carelicensing/subscribe and select the Child Care option to receive email communication.

Appeal rights were provided and discussed, report was reviewed with Ayana Matthews, and the facility has been approved for licensing effective today.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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