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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423969
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:04:23 PM

Document Has Been Signed on 02/06/2025 12:04 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:SMITH, ADRIENAFACILITY NUMBER:
013423969
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
02/06/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Adriena SmithTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 02/06/2025, Licensing Program Analysts (LPAs), A. Hollinger and D. Campos conducted a Case Management - Licensee initiated inspection. Licensee has applied for a capacity increase from a small FCCH (max CAP 8) to a Large FCCH (max CAP 14). Present during today's inspection were licensee, fingerprint cleared assistant, her minor daughter and son as well as 5 children in care consisting of 1 infant and 4 preschoolers. Facility is in ratio today. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 8:00 am to 5:00 pm.

Community Care Licensing (CCL) has received an approved fire clearance on 01/13/2025.

This is a 2-story home which consists of a front living room, main living room, laundry room, 3 bedrooms, two bathrooms, garage, and a backyard.

The On-limit areas: The front living room, main living room, the bathroom, and backyard which are all located on the main level.

The Off- limit areas: The garage, the entire upper level of the home, and a side area connected to the backyard which is divided by a locked door. Off limit areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision at all times.

The fenced backyard was previously marked as off limits. Per Licensee's request the backyard was inspected and included as on limits as of today. There are age appropriate toys in the home. There are no firearms in the home as stated by the licensee. LPA did not observe any hazardous materials or toxins accessible to children today. A sample of children's files and staff files were reviewed. The home has a fully charged 2A10 BC fire extinguisher.
See 809-C for continuance-------------------------------------------------------------------------------
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Hollinger
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SMITH, ADRIENA
FACILITY NUMBER: 013423969
VISIT DATE: 02/06/2025
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The home is equipped with working smoke detector and carbon monoxide detector. There is a working telephone in the home. The applicant’s CPR and First Aid certificate is current and expires 10/2026. Licensee completed mandated reporter training and is current. Licensee is in compliance with immunization requirements. Safe sleep information was discussed with the licensee.

The licensee 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.

Incidental Medical Services (IMS) policy was discussed. 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.

No deficiencies observed at this visit.

The licensee is now approved for a capacity increase to operate as a large family day care home with a maximum capacity of 14 when a fully qualified assistant is present.

A Notice of Site Visit was provided and must remain posted for 30 days.

Exit interview conducted and report reviewed with licensee, Adriena Smith.

SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Hollinger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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