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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013424032
Report Date: 05/27/2025
Date Signed: 05/27/2025 11:45:28 AM

Document Has Been Signed on 05/27/2025 11:45 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:COUCH, OLIVIAFACILITY NUMBER:
013424032
ADMINISTRATOR/
DIRECTOR:		COUCH, OLIVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(341) 667-0211
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/27/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Olivia CouchTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/27/2025, Licensing Program Analysts (LPAs) Dana Santiago and Indira Loza arrived at the large family childcare home for an ANNOUNCED, PRE-LICENSING INSPECTION and met with Applicant, Olivia Couch. LPAs disclosed the purpose of the inspection and was granted entry into the facility by the Applicant. Residing in the home is the Applicant, their spouse who is fingerprint cleared, and their two minor children. Present during the inspection was the Applicant, her spouse, and two minor children. No daycare children were present during this inspection. The facility was toured to conduct a health and safety inspection. The facility plans to operate Mondays, Tuesdays, Thursdays: from 3:00 PM-9:00PM, Wednesdays: 1:30 PM -5:30PM, Saturdays: 8:00 AM - 12:30 PM.

This is a single family house which consists of three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, basement, front and backyard. The facility was observed to be neat and clean with heating and ventilation for the safety and comfort of children in care.

On-limit-areas: Bedroom 1 (bedroom next to the front entrance door), living room, dining area, bathroom 1 (enter by walking through Bedroom 3 which is between the middle Bedroom 2 and Bathroom 2), Bathroom 2 which is connected to dining room, and the backyard.
Off-limit-areas: Front yard behind gate (used as a pass thru to Front Door Entrance), middle Bedroom 2, Bedroom 3 (between Bedroom 2 and Bathroom 2), and the basement. The off-limits areas are made inaccessible by closed/locked doors and 100% visual supervision.
The isolation room is Bedroom 1 away from other children in care.

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NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Dana Santiago
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: COUCH, OLIVIA
FACILITY NUMBER: 013424032
VISIT DATE: 05/27/2025
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The outdoor play area is the fully fenced backyard.

There are ample age-appropriate toys that are observed to be safe, clean and in good repair. LPAs did not observe any hazardous materials or toxins accessible to children during today’s inspection. .

The home has a 4 fully charged 2A10BC fire extinguishers- 2 in the kitchen, 2 in backyard. There is a working smoke alarm and a carbon monoxide detector in the the living room. Applicant was encouraged to conduct monthly tests on these. The home has a working telephone. Applicant states there are no firearms in the home and there is 1 small/medium dog in the home. The Applicant is in compliance with immunization laws which pertain to all childcare providers.

The Applicant has completed the required mandated reporter training which expires 02/2027 and CPR and First Aid certificate expires 06/2026. Applicant was reminded that CPR/First Aid and mandated reporter are to be renewed every two years. The roster of the children must be properly maintained, and a fire/disaster drill must be conducted and documented every six months. Baby bouncers & drop-down cribs are not allowed at the day-care facility. The Applicant is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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 which includes 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.

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NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Dana Santiago
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
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: COUCH, OLIVIA
FACILITY NUMBER: 013424032
VISIT DATE: 05/27/2025
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Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02CCP. 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.

LPAs discussed the safe sleep regulations with 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 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.

LPAs reviewed with Applicant, 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.

In January 2025, 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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


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NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Dana Santiago
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
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: COUCH, OLIVIA
FACILITY NUMBER: 013424032
VISIT DATE: 05/27/2025
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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.


Pending items for Licensure:

- Cover or make inaccessible: Bougainvillea Plant located to the left of tent covering (due to thorns)

- Cover or make inaccessible 2 succulents along the right fence inaccessible (due to thorns)

- Wood post by entrance/exit backdoor: cover or make inaccessible to children

-Provide sketch of basement (OFF limits area)

LPAs Dana Santiago and Indira Loza recommend home for licensure upon Plan of Corrections for above items.

Exit interview conducted and report reviewed with the Applicant, Olivia Couch.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Dana Santiago
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
LIC809 (FAS) - (06/04)
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