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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423969
Report Date: 06/14/2024
Date Signed: 06/14/2024 10:44:42 AM

Document Has Been Signed on 06/14/2024 10:44 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SMITH, ADRIENAFACILITY NUMBER:
013423969
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
06/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Adriena SmithTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 06/14/2024 Licensing Program Analysts (LPAs) K. Sykes and D. Campos arrived for an announced Pre-licensing Inspection. Applicant was previously licensed at a different location. Present for this inspection was applicant Adriena Smith and her fingerprinted spouse Alexander Mostafa. The home was toured with the applicant to conduct a health and safety inspection. Applicant states the hours of operation for day care will be Monday through Friday, 8:00am to 5:00pm.

The home is two story, which consists of a living room, family room, kitchen, backyard, garage, on the first floor; and a master bedroom with bathroom, two additional bedrooms, a laundry room and a hallway bathroom on the second floor. The home is neat and clean with heating and ventilation for safety and comfort.

ON LIMITS: Living room, family room, and bathroom adjacent to garage on the first floor. The isolation area will be the family room.

OFF LIMITS: Kitchen, entire second floor, garage and the back yard. All off limit areas will be inaccessible by closed and/or locked doors and visual supervision. The applicant was advised to contact Licensing, so that an inspection can be completed prior to changing an off limits area to on limits.

Licensee states the backyard is off-limits to day care children until it is ready children to use and instead will bring children to nearby park for outdoor playtime. There are ample age appropriate toys which are observed to be safe, clean and in good repair. There are no pools, hot tubs or any other bodies of water. LPAs did not observe any hazardous materials or toxins accessible to children today. Knives were stored in a locked drawer inaccessible to children today. The home has a fully charged 3A40BC fire extinguisher, working carbon monoxide and smoke detectors, telephone, and fully stocked first aid kit. Heater vents are located on the wall and the ceiling. Per applicant, there are no firearms in the home. Licensee states there are no pets in the home.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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 2
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: SMITH, ADRIENA
FACILITY NUMBER: 013423969
VISIT DATE: 06/14/2024
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The applicant’s health and safety training has been completed, and First Aid/CPR certificate is current, expiring on 11/2024 . A copy of the lease agreement has been reviewed and shows control of property. The applicant has provided proof of the required immunizations, and the required mandated reporter training was completed on 11/2022. Safe Sleep practices, and Effects of Lead Exposure and testing requirements information brochures were discussed and provided. Applicant was reminded that children are never to be left in a parked vehicle.

Individual Medical Services (IMS) policy was discussed. Per licensee, no IMS is being provided at this time. The licensee was reminded that when any changes to the IMS plan is made, an updated 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.”

The applicant was reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. The applicant was reminded of the responsibility as a mandated reporter.


LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

This home is approved for licensure as of today.

This report shall remain on file for 3 years.

Exit interview conducted with Adriena Smith, and copy of report provided.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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